LIBRARY OF CONGRESS. 

©pp/....,., ©np^rigll "J^a 

Shelf .l^.a.2. 

U_Si3_^_ 

UNITED STATES OF AMERICA. 



A TEEATISE 



ON 




THE SCIENCE AND PRACTICE 



MIDWIFEET. 



/ 



BY 



W. S. PLAYFAIR, M.D., LL.D., F.R.C.P., 

PHYSICIAN-ACCOUCHEUK TO H. I. AKD K. H. THE DUCHESS OF EDINBURGH ; PROFESSOR OF OBSTETRIC 
MEDICINE IN KING'S COLLEGE; PHYSICIAN FOR THE DISEASES OF WOMEN AND CHILDREN TO 
king's college HOSPITAL ; CONSULTING PHYSICIAN TO THE GENERAL LYING-IN HOS- 
PITAL AND TO THE EVELINA HOSPITAL FOR CHILDREN; LATE PRESIDENT 
OF THE OBSTETRICAL SOCIETY OF 1-ONDON ; EXAMINER IN MID- 
WIFERY TO THE UNIVERSITY OF LONDON AND TO 
THE ROYAL COLLEGE OF PHYSICIANS. 



FIFTH AMERICAN FROM THE SEVENTH ENGLISH EDITION. 



/5„ 



WITH NOTES AND ADDITIONS 

BY 

ROBERT R HARRIS, M.D. 



WITH FIVE PLATES AND TWO HUNDRED AND SEVEN ILLUSTRATIONS. 




PHILADELPHIA : 

LEA BROTHERS vt CO 

1889. 



^ Gr s%^^ 



fi 






Entered according to Act of Congress, in the year 18S9, by 
LEA BROTHERS & CO., 
in the OflSce of the Librarian of Congress at "Washington. All rights reservi 



Westcott & Thomson, William J. Dornan, 

Stereotypers and Eledrotypem, Philada. Printer, Philada. 



EDITOR'S PREFACE 

TO THE 

FIFTH AMEEIOA]Sr EDITION. 



Four years have passed since the last American edition was issued, 
and this period has worked a revolution in the results attained in sev- 
eral forms of obstetric surgery : notably is this the case in the Porro- 
Csesarean operation ; the conservative Csesarean operation ; and the 
exsective method of treating extra-uterine pregnancy where the foetus 
is alive and of viable development. The Porro operation has fallen in 
its rate of mortality since 1884 from 58 to less than 20 per cent. ; and 
the Conservative or Improved Csesarean, from 45 per cent, to a general 
average of 20 per cent., and for Continental Europe of 12. The 
exsective operation named had had but one case prior to 1885, but 
has now had five without the death of a mother. These facts are not 
mentioned in the last English edition. Laparo-elytrotomy, which was 
attracting considerable attention four years ago, has almost ceased to 
exist, by reason of the diminished death-rate under the improved 
Csesarean section, which in Germany has been one case lost in eight. 
Laparo-elytrotomy has therefore not been performed since September 
18, 1887. The Editor has brought up the work to date upon these 
subjects, and their statistical records to the close of the year 1888. All 
of the American additions, except the article upon the forceps, have 
been either rewritten or remodelled, and many new and short notes 
have been added where required. The work has been sufticientlv 
Americanized, upon the points where English and American obstetri- 
cians differ in opinion and practice, to fit it for the uses of Anioricau 
medical students and obstetricians. All notes and additions have boon 
distinguished by enclosure in brackets [ ]. 

329 South 12Tn STRi':pn\ PniLADELriiiA, 
July 11, 1SS9. 



AUTHOR'S PREFACE 

TO THE 

SEVENTH ENGLISH EDITION. 



The Author has again the satisfaction of presenting to the profes- 
sion a new edition of his work. Since the last edition has been 
exhausted in about two years, there are necessarily not many changes 
to make ; still, the whole has been carefully revised, some portions have 
been re- written, and several new illustrations have been added. The 
chief change in this edition, however, is that the obstetric nomenclature 
decided on by a committee appointed at the International Medical Con- 
gress, held at Washington in 1887, has been introduced. This com- 
mittee was presided over by Professor A. R. Simpson of Edinburgh, 
and there can be little doubt that its recommendations will eventually 
be generally adopted, and will lead to something like uniformity in 
obstetric description. The Author has hitherto not used letters in 
describing the various cranial positions and the like, chiefly because he 
personally thought them rather pedantic and not necessarily leading to 
simplicity. Now, however, that so authoritative a committee has pro- 
nounced in their favor, and that there is a reasonable hope of the same 
letters being employed by writers in various countries, he has thought 
it advisable to introduce them in brackets, so as to give his readers the 
opportunity of familiarizing themselves with their use. The Author 
has once more to express his grateful thanks to Dr. W. Tyreei.l 
Brooks of Oxford, to his colleague Professor Crookshaxk of King's 
College, and to Dr. John Phillips, for their valuable assistance. V^v. 
Brooks has, for the second time, revised the chapters on conception 
and generation ; Dr. Cr(^okshank has done the same with referonoo 
to the bacteriology of i)uerperal septicjemia ; and Dr. Phillips, as on 
several previous occasions, has spared the Author iiiucli labor by his 
aid in passing the work through the press. 

31 Georue Street, Hanover Square, 
January, ISS'K 



PREFACE TO THE FIRST EDITlOiN, 



Those who have studied the progress of Midwifery know that there 
is no department of medicine in which more has been done of late years, 
and none in which modern views of practice diiFer more widely from 
those prevalent only a short time ago. The Author's object has been to 
place in the hands of his readers an epitome of the science and practice 
of midwifery which embodies all recent advances. He is aware that on 
certain important points he has recommended practice which not Ions: 
ago would have been considered heterodox in the extreme, and which 
even now will not meet with general approval. He has, however, the 
satisfaction of knowing that he has only done so after very deliberate 
reflection, and with the profound conviction that such changes are right 
and that they will stand the test of experience. He has endeavored to 
dwell especially on the practical part of the subject, so as to make the 
Avork a useful guide in this most anxious and responsible branch of the 
profession. It is admitted by all that emergencies and difficulties arise 
more often in this than in any other branch of practice ; and there is no 
part of the practitioner's work which requires more thorough knowledge 
or greater experience. It is, moreover, a lamentable fact that students 
generally leave their schools nu)re ignorant of obstetrics than of anv 
other subject. So long as tli^ absurd regulations exist which oblige the 
lecturer on midwifery to attempt the impossible task of teaching obstet- 
rics in a short three months' course — an absurdity which has over and 
over again been pointed out — such nuist of necessity be the case. Tiiis 
nuist be the Author's excuse ibr dwelling t>n inanv topics at iireater 
length than some will doubtless think tluMr importance merits, simv he 
dc^sires to place in the hands oi\ his students a work whieh nuiv in some 
measure su])ply the inevitable detects ot' his leetures. 



viii PREFACE TO THE FIRST EDITION. 

Many of the illustrations are copied from previous authors, while 
some are original. The following quotation from the preface to Tyler 
Smith's Manual of Obstetrics will explain why the source of the copied 
wood-cuts has not been in each instance acknowledged : " When I began 
to publish, I determined to give the authority for every wood-cut copied 
from other works. I soon found, however, that obstetric authors of all 
countries, from the time of Mauriceau downward, had copied each other 
so freely without acknowledgment as to render it difficult or impossible 
to trace the originals." 

The Author has to express his acknowledgments to many friends for 
their kind assistance by the loan of illustrations and otherwise, and more 
especially to his colleague. Dr. Hayes, for his valuable aid in passing 
the work through the press. 

31 George Street, Hanover Square, 
March, 1876. 



CONTENTS 



PART L 



ANATOMY AND PHYSIOLOGY OF THE ORGANS CONCERNED 
IN PARTURITION. 



CHAPTEK I. 

ANATOMY OF THE PELVIS. 

PAGE 

Its importance — Formation of Pelvis — The os innominatum ; its three divisions 
— Separation between the True and False Pelvis — The Sacrum and Coccyx- 
Mechanical relations of the Sacrum — Pelvic articulations and ligaments — 
Movements of the Pelvic Joints — The Pelvis as a whole — Difibrences in the 
two sexes — Measurements of the Pelvis — Its diameters, planes, and axes — 
Development of the Pelvis— Soft parts in connection with the Pelvis .... 33 



CHAPTEK II. 

THE FEMALE GENERATIVE ORGANS. 

Division accordinoj to Function : 1. External or Copulative ; 2. Internal or Forma- 
tive Organs — Mons Veneris — Labia majora and minora — The Clitoris — The 
Vestibule and Orifice of Urethra — Passing of the female catheter — Orifice of 
Vagina — The PJymen — The glands of the Vulva — The Perineum— The Va- 
gina — The Uterus : its position and anatomy — [Partitioned Uterus] — The 
ligaments of the Uterus — The Parovarium — The Fallopian Tubes — The 
Ovaries — The Graafian Follicles and the Ova — The Mammarv Ct lauds . . 49 



CHAPTER III. 

OVULATION AND MENSTRUATION. 

Functions of the Ovary — Changes in the (fraalian Follicle: 1. Maturation; 2. Es- 
cape of the Ovum — Formation of the Corpus Luteum — [Precocious Physical 
AVomanhood] — Quality and^source of the Menstrual blood — Theory o( Men- 
struation — Puvi>ose of the Menstrual loss — A'icarious Menstruation — Cess;\tion 
of Menstruation SI 



CONTENTS. 

PART II. 
PREGNANCY 



CHAPTER I. 

CONCEPTION AND GENERATION. 

PAGE 

The Semen — Site and mode of Impregnation — Changes in the Ovum — Cleavage 
of the Yelk — The Decidua and its formation — Formation of the Amnion — 
The Umbilical Vesicle and Allantois — The Liquor Amnii and its uses — The 
Chorion — The Placenta ; its formation, anatomy, and functions 95 

CHAPTER n. 

THE ANATOMY AND PHYSIOLOGY OF THE FCETUS. 

Appearance of the Foetus at various stages of development — [Very Small Foetuses 
habitually produced by some mothers] — Anatomy of the Foetal Head — The 
Sutures and Fontanelles — Influence of Sex and Race on the Foetal Head — 
Position of the Foetus in utero — Functions of the Foetus — The Foetal Circula- 
tion 121 

CHAPTER III. 

PREGNANCY. 

Changes in the form and dimensions of the Uterus— Changes in the Cervix — 
Changes in the texture of the Uterine Tissues, the Peritoneal, Muscular, and 
Mucous Coats — General modifications in the Body produced by Pregnancy . 136 

CHAPTER IV. 

SIGNS AND SYMPTOMS OF PREGNANCY. 

Signs of a fruitful Conception— Cessation of Menstruation — [Double uterus, one- 
half pregnant, the other Menstruating]— Sympathetic Disturbances — Morning 
Sickness, etc. — Mammary Changes — Enlargement of the Abdomen— Quicken- 
ing — Intermittent Uterine Contractions — [Intermittent uterine contractions of 
Pregnancy sometimes painful]— Vaginal signs of Pregnancy— Ballottement, 
etc. — Auscultatory Signs of Pregnancy— Foetal Pulsations — Uterine Souffle, etc. 147 

CHAPTER V. 

THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY — SPURIOUS PREGNANCY— THE 
DURATION OF PREGNANCY— SIGNS OF RECENT PREGNANCY. 

Adipose enlargement of the Abdomen— Distension of the Uterus by retained 
Menses, etc. — Congestive enlargement of Uterus — Ascites — Uterine and Ova- 
rian Tumors — Spurious Pregnancy ; its Causes, Symptoms, and Diagnosis — The 
Duration of Pregnancy — Sources of Fallacy — Methods of predicting Date of 
Delivery — Protraction of Pregnancy — Signs of recent Delivery 161 



CONTENTS. XI 

CHAPTEE VI. 

ABNORMAL PREGNANCY, INCLUDING MULTIPLE PREGNANCY, SUPERFCETATIOX. 
EXTRA-UTERINE FCETATION, AND MISSED LABOR. 

PAGE 

Plural Births; their Frequency, relative Frequency in different Countries, Causes, 
etc. — Superfoetation and Snperfecundation — Nature — Explanation — Objec- 
tions to admission of such cases — Their possibility admitted — Extra-uterine 
Pregnancy — Classification — Causes— Tubal Pregnancies — Changes in the Fal- 
lopian Tubes — Condition of Uterus — Progress and Termination — Diagnosis — 
Treatment — [Extra-uterine pregnancy] — [Toxic injections in extra-uterine 
pregnancy dangerous] — Abdominal Pregnancy; Description, Diagnosis, 
Treatment — [Exsection of cyst and placenta after removal of a living and 
viable Foetus in extra-uterine pregnancy] — Missed Labor; its Symptoms, 
Causes, and Treatment— [Causes of Missed Labor] 170 



CHAPTER VII. 

DISEASES OF PREGNANCY. 

Some only Sympathetic, others Mechanical or Complex in their Origin — Derange- 
ments of the Digestive Organs; Excessive Nausea and Vomiting, Diarrhoea, 
Constipation, Hemorrhoids, Ptyalism, etc. — [Cough of pregnancy] — Dyspnoea 
— [Dyspnoea of pregnancy] — Palpitation — Syncope — Ansemia and Chlorosis — 
[Pernicious ansemia in parturient women] — Albuminuria 199 



CHAPTER VIIL 

DISEASES OF PREGNANCY {continued). 

Disorders of the Nervous System ; Insomnia, Headaches and Neuralgia, Paraly- 
sis—Chorea ; Disorders of the Urinary Organs ; Retention of Urine, Irrita- 
bility of the Bladder — [Eneuresis of pregnancy] — Incontinence of Urine, 
Phosphatic Deposits — Leucorrhoea — Effects of Pressure — Laceration of Veins 
— Displacements of the Gravid Uterus; Prolapse, Anteversion, Retroversion 
— Diseases co-existing with Pregnancy : Eruptive Fevers, Smallpox, Measles, 
Scarlet Fever, Continued Fever, Phthisis, Cardiac Disease, Syphilis, Icterus, 
Carcinoma — Pregnancy complicated with Ovarian and Fibroid Tumors . . . 212 



CHAPTER IX. 

PATHOLOGY OF THE DECIDUA AND OVUM. 

Pathology of the Decidua— Hydrorrluva Gravidarum— Pathology of the Chorion ; 
Vesicular Degeneration, Myxoma Fibrosum — Patliology of the Phuvnta ; 
Blood- Extravasations, Fatty Degeneration, etc. — Pathology of tlie I'mbilioal 
Cord — [Corkscrew funis] — Pathology of the .\nniion — [Hydranniios] — De- 
ficiency of Liquor Anniii, etc. — Pathology o'( (ho Fivtus ; Blood Diseases- 
through the Mother, Smallpox, Measles, and Scarlet Fever, Intermittent 
Fevers, Lead- Poisoning, Syphilis— inliammatory Diseases — Dropvsies— Tinnors 
— Wounds and Injuries of the Fcvtus- Intra-uterine Amputations— [A rrestetl 

pullulation] — Death of the Fa>tus 229 

iJ 



xu CONTENTS. 

CHAPTER X. 

ABORTION AND PREMATURE LABOR. 

PA.GE 
Importance and Frequency — Definition and Classification — Frequency — Recur- 
rence — Causes — Causes referable to Foetus — Changes in a Dead Ovum retained 
in Utero — Extravasations of Blood — Moles, etc. — Causes depending on Mater- 
nal State, Syphilis — Causes acting through Nervous System, Physical Causes, 
etc. — Causes depending on Morbid States of Uterus — Symptoms — Preventive 
Treatment — [Opiate treatment in threatened abortion] — Prophylactic Treat- 
ment — [Viburnum prunifolium in threatened abortion] — Treatment when 
Abortion is inevitable — After-treatment 247 



PART III. 

LABOR. 



CHAPTER I. 

THE PHENOMENA OF LABOR. 

Causes of Labor — Mode in Avhich the Expulsion of the Child is effected — The 
Uterine contraction — Mode in which the Dilatation of the Cervix is effected 
— Rupture of the Membranes — Character and source of Pains during Labor 
— Effect of Pains on Mother and Foetus — Division of Labor into Stages — 
Preparatory Stage — False Pains — First Stage — Second Stage — Third Stage — 
Mode in which the Placenta is expelled — Duration of Labor 259 

CHAPTER n. 

MECHANLSM OF DELIVERY IN EIEAD PRESENTATIONS. 

Importance of Subject — Frequency of Head Presentation — The different positions 
of the Head — First Position — Division of Mechanical movements into Stages 
— Flexion — Descent and Levelling Movement — Rotation — Extension— Exter- 
nal Rotation — Second Position — Third Position — Fourth Position — Caput 
Succedaneum — Alteration in Shape of Head from Moulding 272 

CHAPTER TIL 

MANAGEMENT OF NATURAL LABOR. 

Preparatory Treatment — Dress of Patient during Pregnancy — The Obstetric Bag 
— Duties on first visiting Patient — False Pains — Their Character and Treat- 
ment — [Kelly's rubber protector in parturient cases] — Vaginal Examination 
— The Position of Patient — Artificial Rupture of Membranes — Treatment of 
Propulsive Stage — Relaxation of the Perineum — Treatment of Lacerations — 
Expulsion of Child — Promotion of Uterine Contraction — Ligature of the Cord 
— Management of the Third Stage of Labor — [Expulsion of Placenta] — Ap- 
plication of the Binder — After-treatment 284 



CONTENTS. 
CHAPTER IV. 



Xlll 



ANAESTHESIA IN LABOR. 



Agents employed — Chloral ; its Object and Mode of Administration — Ether — 
Chloroform; its Use, Objections to, and Mode of Administration — [Ether safer 
than Chloroform] 299 



CHAPTER V. 

PELVIC PRESENTATIONS. 

Frequency — Causes — Prognosis to Mother and Child — Diagnosis by Abdominal 
Palpation and by Vaginal Examination — [Bimanual Version in breech cases] 
— Differential Diagnosis of Breech, Knee, and Feet — Mechanism — Treatment 
— Management of Impacted Breech Presentations — [Breech forceps] .... 303 



CHAPTER VI. 

PRESENTATIONS OF THE FACE. 

Erroneous Views formerly held on the Subject — Frequency — Mode of Production 
— Diagnosis — Mechanism — Four Positions of the Face — Description of De- 
livery in First Face Position — Mento-posterior Position in which Rotation 
does not take place — Prognosis — Treatment — Brow Presentation — [Version 
by the Vertex] 315 



CHAPTER VII. 

DIFFICULT OCCIPITO-POSTERIOR POSITIONS. 

Causes of Face-to-Pubes Delivery — Mode of Treatment— Upward Pressure on 
Forehead — Downward Traction on Occiput — Use of Forceps — Peculiarities 
of Forceps Delivery 324 

CHAPTER VIII. 

PRESENTATIONS OF SHOULDER, ARM, OR TRUNK-COMPLEX PRESENTATIONS- 
PROLAPSE OF THE FUNIS. 

Position of the Foetus — Division into Dorso-anterior and Dorso- posterior Posi- 
tions — Causes — Prognosis and Frequency — Diagnosis — Mode of distinguishing 
Position of Child— Diflerential Diagnosis of Shoulder, Elbow, and Hand- 
Mechanism — The two possible INIodes of Delivery by the Natural Powers — 
Spontaneous Version — Spontaneous Evolution — Treatment — [C;vsaroan Opera- 
tion for fuHal impaction] — Complex Prosoutatiou ; Foot or Hand with Head; 
Hand and Feet together — Dorsal nis{>lacou\ent of the Arm — Prolapse o( the 
Umbilical Cord — Frequency — Prognosis— Cruises— Diagnosis — Postural Treat- 
ment — Artiticial Reposition — Treatment when Kopositiou fails 32S 



XIV CONTENTS. 

CHAPTER IX. 

PROLONGED AND PRECIPITATE LABORS. 

PAGE 

Evil Effects of Prolonged Labor — Influence of the Stage of Labor in Protraction 
— Delay in the First Stage rarely serious — Temporary Cessation of Pains — 
Symptoms of Protraction in the Second Stage— State of the Uterus in Pro- 
tracted Labor — Causes of Protraction due to morbid condition of the expul- 
sive powers — [Recurrent Uterine Fatigue] — Causes of Protraction — Treatment 
— Oxytocic Remedies — Ergot of Rye, etc. — Manual Pressure — Instrumental 
Delivery (case of Princess Charlotte of Wales) — [Frequent use of Forceps] — 
Precipitate Labor — Its Causes and Treatment — [Rapid Delivery] 342 

CHAPTER X. 

LABOR OBSTRUCTED BY FAULTY CONDITION OF THE SOFT PARTS. 

Rigidity of the Cervix ; its Causes, Effects, and Treatment — [Csesarean Section in 
Cancer of Cervix] — Ante-partum Hour-glass Contraction — [" Circular Contrac- 
tion of the middle of the Womb" (Blundell)] — Bands and Cicatrices in the 
Vagina — Extreme Rigidity of the Perineum — Labor complicated with Tumor 
— [Csesarean Results in Tumor Cases] — [Prolapsed Dermoid Cyst obstructing 
Delivery] — Vaginal Cystocele — Calculus — Hernial Protrusions — [Impaction 
of Bowels from eating Clay] — OEdema of Vulva — Hsematic Effusions, etc. — 
[Polypus obstructing Delivery] 358 

CHAPTER XI. 

DIFFICULT LABOR DEPENDING ON SOME UNUSUAL CONDITION OF THE FCETUS. 

Plural Births, Treatment of — Locked Twins — Conjoined Twins — Intra-uterine 
Hydrocephalus : Its Dangers, Diagnosis, and Treatment — Other Dropsical 
Effusions— Foetal Tumors — Excessive Development of Foetus 370 

CHAPTER XII. 

DEFORMITIES OF THE PELVIS. 

Classification — Causes of Pelvic Deformity — Rickets and Osteomalacia — The 
Equally-Enlarged Pelvis — The Equally-Contracted Pelvis — The Unde- 
veloped Pelvis — [Small Pelvis, marked by External Development of Adi- 
pose Tissue] — Masculine or Funnel-shaped Pelvis — Contraction of Conjugate 
Diameter of the Brim — [Spinal and Pelvic Deformity associated] — Figure- 
of-eight Deformity — [Spondyl-olisthesis] — Spondylolizema — Narrowing of the 
Oblique Diameters — [Osteomalacia not an American Disease]— Obliquely-Con- 
tracted Pelvis — [Coxalgic Deformity of Pelvis] — Kyphotic Pelvis — Robert's 
Pelvis — Deformity from old-standing Hip-joint Disease — Deformity from 
Tumors, Fractures, etc. — Effects of Contracted Pelvis on Labor — Risks to 
the ]\Iother and Child — [Pelvic Exostosis obstructing Delivery] —Mechan- 
ism of Delivery in Head Presentation : a, in Contracted Brim , b, in Generally- 
Contracted Pelvis — Diagnosis — External Measurements — Internal Measure- 
ments—Mode of Estimating the Conjugate Diameter of the Brim — Mode of 
Diagnosing the Oblique Pelvis — Treatment — The Forceps — Turning — Crani- 
otomy — The Induction of Premature Labor — Induction of Abortion — [Dan- 
gers of Csesarean Section Overestimated] 382 



CONTENTS. XV 

CHAPTER XIII. 

HEMORRHAGE BEFORE DELIVERY: PLACENTA PREVIA. 

PAGE 

Definition — Causes — Symptoms — Sources and Causes of Hemorrhage — Prognosis 
— Treatment — [Braxton Hicks' Bimanual Method of Turning in Placenta 
Prsevia] 407 

CHAPTER XIV. 

HEMORRHAGE FROM SEPARATION OF A NORMALLY SITUATED PLACENTA. 
Causes and Pathology — Symptoms and Diagnosis — Prognosis — Treatment . . . 418 

CHAPTER XV. 

HEMORRHAGE AFTER DELIVERY. 

Its Frequency— Generally a Preventable Accident — Causes— Nature's Method 6\ 
Controlling Hemorrhage — Uterine Contraction — Thrombosis — Secondary 
Causes' of Hemorrhage — Irregular Uterine Contraction — Placental Adhesions 
— Constitutional Predisposition to Flooding — Symptoms — Preventive Treat- 
ment — Curative Treatment — Secondary Treatment — [Hot-Avater Injections of 
Uterus] — [Head Lowered and Body Elevated in Fainting from Hemorrhage] 
— Secondary Post-partum Hemorrhage — Its Causes and Treatment 421 

CHAPTER XVI. 

RUPTURE OF THE UTERUS, ETC. 

Its Fatality— Seat of Rupture— Causes, Predisposing and Exciting — Symptoms 
— Prognosis— Treatment ; when the Fcetus Remains in utero, when the Fanus 
has Escaped from the Uterus— [Prevot's Supravaginal Amputation of Uterus] 
— Lacerations of the Cervix — Recapitulation — Lacerations of the Vagina — 
Vesico- and Recto-vaginal FistuljTe— Their Mode of Formation— Treatment— 
[Rational Treatment of Rupture of the Uterus] 43S 



CHAPTER XVII. 

INVERSION OF THE UTERUS. 

Division into Acute and Chronic F(n-ms—Description— Symptoms — Diagnosis- 
Mode of Production — Treatment — [Spontaneous Reposition of iho Invortod 
Uterus] 441) 



xvi COXTEXTS. 



PART IV. 

OBSTETRIC OPERATIOXS. 



CHAPTER I. 

INDUCTION OF PREMATURE LABOR. 

PAGE 

History — Objects — May be Performed on account either of the Mother or Child 
— Modes of Inducing Labor — Puncture of Membranes — Administration of 
Oxytocics — Means acting Indirectly on the Uterus — Dilatation of Cervix — 
Separation of Membranes — Vaginal and Uterine Douches — Introduction of 
Flexible Catheter — [Infantile Mortality after Induction of Premature Labor] 456 



CHAPTER II. 

TURNING. 

History — Turning by External Manipulation— Object and Nature of the Opera- 
tion — Cases Suitable for the Operation — Statistics and Dangers — Method of 
Performance — Cephalic Version — Method of Performance — Podalic Version 
— Position of Patient — Administration of Anaesthetics — Period when the 
Operation should be Undertaken — Choice of Hand to be Used — Turning by 
Bipolar Method — Turning Avhen the Hand is Introduced into the Uterus — 
Turning in Abdomino-anterior Positions — Difficult Cases of Arm Presentation 
— [The Forceps in America] 464 



CHAPTER III. 

THE FORCEPS. 

Frequent Use of the Forceps in Modern Practice — Description of the Instrument 
— The Short Forceps — Its Varieties— The Long Forceps — Suitable to all Cases 
alike — Action of the Instrument — Its Power as a Tractor, Lever, and Com- 
pressor — Preliminary Considerations before Operation — Use of Anaesthetics — 
Description of the Operation — Low Forceps Operation — High Forceps Opera- 
tion — Possible Dangers of Forceps Delivery — Possible Risks to the Child . . 47J 



CHAPTER IV. 

THE VECTIS— THE FILLET. 

Nature of the Vectis — Its Use as a Lever or Tractor — Cases in which it is Appli- 
cable — Its Use as a Rectifier of Malpositions — The Fillet — Nature of the 
Instrument — Objections to its Use * 502 



CONTENTS. xvu 

CHAPTER V. 

OPERATIONS INVOLVING DESTRUCTION OF THE FCETUS. 

PAGE 

Their Antiquity and History— Division of Subject — Nature of Instruments Em- 
ployed — Perforator — Crotchet — Craniotomy Forceps — Cephakjtribe — Forceps- 
saw — Ecraseur — Basilyst — Cases requiring Craniotomy — Method of Perfoia- 
tion — Extraction of the Head — Comparative Merits of Cephalotripsy and 
Craniotomy — Extraction by the Craniotomy Forceps — Extraction of the Body 
— [Meigs' Craniotomy Forceps] — Embryotomy — Decapitation and Eviscera- 
tion , 504 



CHAPTER VL 

THE CESAREAN SECTION— PORRO'S OPERATION-SYMPHYSIOTOMY. 

History of the Operation — [Macduff's Delivery] — Statistics — [Old Ceesarean Rec- 
ords of little Practical Value now] — [Csesarean Section in America] — Re- 
sults to Mother and Child — Causes Requiring the Operation — [Cesarean Sec- 
tion under Relative Indications] — Post-mortem Csesarean Section — Causes of 
Death after the Csesarean Section — [Ceesarean Section, causes of Death fol- 
lowing] — [Csesarean Section performed Prior to Labor] — Preliminary Prepa- 
rations — [Color-line of Abdomen in Pregnant Women] — Description of the 
Operation — [Sutures in Csesarean Operations] — Subsequent Management— 
Porro's Operation — [Porro Operation in Great Britain] — [Porro Statistics] — 
Substitutes for the Csesarean Section — Symphysiotomy — [Symphysiotomy in 
Naples] 518 



CHAPTER VII. 

LAPARO-ELYTROTOMY. 

History — [Statistics of Laparo-elytrotomy] — Nature of the Operation — Advan- 
tages over the Csesarean Section — Cases Suitable for the Operation — [Laparo- 
elytrotomy Inadmissible in many Cases of Labor] — Anatomy of the Parts 
concerned in the Operation — Method of Performance — Subsequent Treatment 
— [Laparo-elytrotomy performed on Either Side] 53-4 



CHAPTER VIII. 

THE TRANSFUSION OF BLOOD, 

History — Nature and Object of the Operation— Use of Blood taken from the 
Lower Animals — Difliculties from Coagulation of Fibrin— Modes of Obviat- 
ing them — Immediate Transfusion — Addition of Chemical Agents to prevent 
Coagulation — Delibrination of the Blood— Statistical Results — P(\-<siblo Dan- 
gers of the Operation — Cases suitable for Transfusion— Description of the 
Operation — Schiifer's Direcfions lor Immediate Transtusion - Ktiocts o( Siu- 
cessful Transfusion — Secondary b'llocis oi' Transf"u8iou — [Traustusiou with 
Delibrinated Blood] 5oJ 



xviu coy TEXTS. 

PART Y. 

THE PUERPERAL STATE. 



CHAPTEK I. 

THE PUERPERAL STATE AND ITS MANAGEMENT. 

PAGE 

Importance of Studying the Puerperal State — The Mortality of Childbirth — 
Alterations in the Blood after Delivery — Condition after Delivery — Xervous 
Shock — Fall of the Pulse — The Secretions and Excretions — Secretion of Milk 
— Changes in the Uterus after Delivery — The Lochia — The After-pains — 
Management of Women after Delivery — Treatment of Severe After-pains — 
Diet and Kegimen 551 

CHAPTEK II. 

MANAGEMENT OF THE INFANT, LACTATION, ETC. 

Commencement of Eespiration after the Birth of the Child — Apparent Death of 
the Newborn Child — Its Treatment — "Washing and Dressing the Child — Ap- 
plication of the Child to the Breast — The Colostrum and its Properties — Secre- 
tion of Milk — Importance of Nursing — Selection of a Wet-nurse — [Diet proper 
for Wet-nurses] — Management of Lactation — Diet and Eegimen of Nursing 
Women — Period of AVeaning — Disorders of Lactation — Means of Arresting 
the Secretion of Milk — Defective Secretion of Milk — [Milk-diet for Nursing 
Mothers] — Depressed Nipples — Fissures and Excoriations of the Nipples — 
Excessive Flow of Milk — Mammary Abscess — Hand-feeding — Causes of Mor- 
tality in Hand-feeding — Various Kinds of Milk — Method of Hand-feeding . 562 

CHAPTER HI. 

PUERPERAL ECLAMPSIA. 

Its Doubtful Etiology — Premonitory Symptoms — Symptoms of the Attack — Con- 
dition between the Attacks — Relation of the Attacks to Labor— Results to 
Mother and Child— Pathology— Treatment— Obstetric Management — [Urine 
to be Examined in Eclamptic Cases] 578 

CHAPTER IV. 

PUERPERAL INSANITY. 

Classification— Proportion of Various Forms — Insanity of Pregnancy — Predis- 
]iosing Causes — Period of Pregnancy at which it Occurs — Type of Insanity — 
Prognosis —Transient Mania during Delivery — Puerperal Insanity (proper) 
— Type of Insanity — Causes— Theory of hs Dependence on a Morbid State of 
the Blood — Objections to the Theory — Prognosis — Post-mortem Signs — Dura- 
tion — Insanity of Lactation — Type— Symptoms — Of Mania — Of Melancholia 
— Treatment— Question of Removal to Asylum — Treatment during Conva- 
lescence 587 



CONTENTS. xix 

CHAPTER V. 

PUERPERAL SEPTICEMIA. 

PAGE 

Differences of Opinion — Confusion from tliis Cause — Modern View of this Dis- 
ease — History — Its Mortality in Lying-in Hospitals — Numerous Theories as 
to its Nature — Theory of Local Origin — Theory of an Essential Zymotic 
Fever — Theory of its Identity with Surgical Septicaemia — Nature of this 
View — Channels through which Septic Matter may be Absorbed — Character 
and Origin of Septic Matter often Obscure — Division into Autogenetic and 
Heterogenetic Cases — Sources of Self-infection — Sources of Heterogenetic 
Infection — Influence of Cadaveric Poison — Infection from Erysipelas — Infec- 
tion from other Zymotic Diseases — Infection from Sewer Gas — Cases illustrat- 
ing this Mode of Infection — Contagion from other Puerperal Patients — Mode 
in which the Poison m^y be Conveyed to the Patient — Conduct of the Prac- 
titioner in Relation to the Disease — Nature of the Septic Poison — Local Changes 
resulting from the Absorption of Septic Material — Channels through 
which Systemic Infection is Produced — Pathological Phenomena observed 
after general Blood Infection — Four Principal Types of Pathological Change 
— Intense Cases without marked Post-mortem Signs — Cases Characterized by 
Inflammation of the Serous Membranes — Cases Characterized by the Impac- 
tion of Infected Emboli and Secondary Inflammation and Abscess — Descrip- 
tion of the Disease — Duration — Varieties of Symptoms in Different Cases — 
Symptoms of Local Complications — Treatment 598 



CHAPTER VI. 

PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 

Puerperal Thrombosis and its Results — Conditions which favor Thrombosis — Con- 
ditions which favor Coagulation in the Puerperal State — Distinction between 
Thrombosis and Embolism — Is Primary Thrombosis of the Pulmonary Arteries 
possible? — History— Symptoms of Pulmonary Obstruction — Is Recovery pos- 
sible ? — Causes of Death — Post-mortem Appearances — Treatment — Puerperal 
Pleuro-pneumonia ; its Causes and Treatment 629 



CHAPTER VII. 

PUERPERAL ARTERIAL THROMBOSIS AND EMBOLISM. 
Causes— Symptoms — Treatment 641 

CHAPTER VIII. 

OTHER CAUSES OF SUDDEN DEATH DURING LABOR AND THE PUERPERAL STATE. 

Organic and Functional Causes — Idiopathic Asphyxia— Puliuonary Apoplexy — 
Cerebral Apoplexy — Syncope — Shock and Exhaustion — Entrance ot' Air into 
the Veins 643 



XX COXTEXTS. 



CHAPTER IX. 

PERTPEIERAL VENOUS THROMBOSIS (SYN. : CRURAL PHLEBITIS-PHLEGMASIA 
DOLENS— ANASARCA SEROSA— (EDEMA LACTEUM— "WHITE LEG, ETC.) 

PAGE 

Nature — Symptoms — History and Pathology — Anatomical Form of the Thrombi 
in tlie Veins — Detachment of Emboli — [Crural Phlebitis after Csesarean and 
Porro Operations] — Treatment 645 



CHAPTER X. 

PELVIC CELLULITIS AND PELVIC PERITONITIS. 

Two Forms of Disease — Variety of Xomenclature — Importance of Differential 
Diagnosis — Etiology — Connection with Septica?raia — wSeat of Inflammation — 
Relative Frequency of the Two Forms of Disease — Symptomatology — Results 
of Physical Examination — Terminations — Prognosis— Treatment 652 



INDEX • • • 661 



ILLUSTRATIONS. 



Plate I. — Section of a Frozen Body in the last months of Pregnancy (after 
Braune). Illustrating the Relations of the Uterus to the surrounding Parts, 
and the attitude of the Foetus, which is lying in the second Cranial Posi- 
tion Frontispiece 

Plate IL — Section of a Frozen Body at the termination of the First Stage of 
Labor (after Braune). Membranes unbroken; Cervix fully dilated; and the 
Head (in the Second Position) in the Pelvic Cavity Frontispiece 

Plate III. — Illustrations of the Corpora Lutea of Menstruation and Pregnancy. 

(After Dalton.) To face page 62 

Plate IV. — Vertical Mesial Section of Uterus with Placenta partially attached. 

(After Barbour.) To face page 110 

Plate V. — Vertical Mesial Section (frozen) of Pelvis with Post-partumL'terus. 

To face page 234 

FIO. PAGE 

1. Os innominatum 34 

2. Sacrum and Coccyx 35 

3. Section of Pelvis and heads of Thigh-bones, showing the Suspensory Action 

of the Sacro-iliac Ligaments. (After Wood.) 36 

4. Outlet of Pelvis 40 

5. The Female Pelvis 40 

6. The Male Pelvis 41 

7. Brim of Pelvis, showing A ntero-posterior, Oblique, and Transverse Diameters 41 

8. Section of Pelvis, showing the Diameters • ■ 42 

9. Planes of the Pelvis, with Horizon 44 

10. Axes of the Pelvis 45 

11. Representing General Axis of the Parturient Canal, including the Uterine 

Cavity and Soft Parts 45 

12. Side view of Pelvis 46 

13. Pelvis of a Child 47 

14. External CJenitals of Virgin with Diaphragmatic Hymen. (After Sappey.) 50 

15. Vascular Supply of Vulva. (After Kobelt.) 54 

16. Right Half of Virgin Vagina with Walls held apart, showing the abundant 

transverse Ruga\ the greater depth of the Vagina above than below, and 

the Hymeneal Segment. (After Hart) 55 

17. Longitudinal Section of Body, showing Relations of the Generative C)igans . 55 

18. Transverse Section of Body, showing Relations of the Fundus Uteri .... 57 

19. Transverse Section of Icterus 57 

20. Uterus and Appendages in an Infant. (After Fa rre.'* 58 

21. Portion of Interior of Cervix. (Fnlarged nine times. ^ 60 

22. Muscular Fibres of Unimpregnatod Uterus. (After Fa rre.) 60 

23. Developed Muscular Fibres; from the Gravid Uterus. (After Wagner. K . . 60 

24. Lining Membrane of Uterus, slunving Network of Capillaries and Orilii'es o\ 

Uterine Glands. (After Farre.) 62 

xxi 



xxii ILL USTEA TIONS. 

^"IG- PAGE 

25. The Course of the Glands in tlie fully-developed Mucous Membrane of the 

Uterus. (After AVilliams.) 63 

26. Vertical Section through the Mucous Membrane of the Human Uterus. 

(After Turner.) 64 

27. Villi of Os Uteri stripped of Epithelium. (After Tyler Smith and Hassall.) 65 

28. Villi of Uterus, covered wiih Pavement Epithelium, and containing Looped 

Vessels. (After Tyler Smith and Hassall.) Qo 

29. Bifid Uterus. (After Farre.) 67 

30. [Uterus Septus Uniforis. (From Kussmaul, after Gravel.)] 68 

31. Adult Parovarium, Ovary, and Fallopian Tube. (After Kobelt.) 69 

32. Posterior View of Muscular and Vascular Arrangements. (After Eouget.) . 70 

33. Fallopian Tube laid open. (After Richard.) 72 

34. Ovary enlarged under Menstrual Nisus 74 

35. Longitudinal Section of Adult Ovary. (After Farre.) 75 

36. Section through the Cortical Part of the Ovary. (After Turner.) 76 

37. A'ertical Section through the Ovary of the Human Foetus. (After Foulis.) . 76 

38. Diagrammatic Section of Graafian Follicle 77 

39. Bulb of Ovary 79 

40. Mammary Gland 80 

41. Section of Ovary, showing Corpus Luteum three weeks after Menstruation. 

(After Dalton.) 83 

42. Corpus Luteum at the fourth month of Pregnancy. (After Dalton.) .... 85 

43. Corpus Luteum of Pregnancy at Term. (After Dalton.) 85 

44. Section of Parts of three Seminiferous Tubules of the Rat. (From a prepara- 

tion by Mr. A. Eraser.) 96 

45. Ovum of a Rabbit containing Spermatozoa 98 

46. Formation of the " Polar Globule " 99 

47. Sections of the Ovum of the Rabbit during the last Stages of Segmenta- 

tion, showing the Formation of the Blastodermic Vesicle. (After E. v. 
Beneden.) 100 

48. Formation of the Blastodermic Membrane. (After Joulin.) 101 

49. Aborted Ovum (of about forty days), showing the Triangular Shape of the 

Decidua (which is laid open), and the Aperture of the Fallopian Tube. 

(After Coste.) 102 

50. -j 

51. r Formation of the Decidua. (After Dalton.) . 103 

52.3 

53. An Ovum i-emoved from the Uterus, and part of the Decidua Vera cut away. 

(After Coste.) 104 

54. Diagram of Area Germinativa, showing the Primitive Trace and Area Pel- 

lucida 106 

55. Development of the Amnion 107 

56. Development of tlie Umbilical Vesicle and Amnion 108 

57. An Embryo of about twenty-five days laid open. (After Coste.) 108 

58. Development of the Chorion 109 

59. Five diagrammatic Figures illustrating the Formation of the Foetal Mem- 

branes of a Mammal. (After Kolliker.) Ill 

60. Placental Villus, greatly magnified. (After Joulin.) 115 

61. Terminal Villus of Foetal Tuft, minutely ejected. (After Farre.) 116 

62. Diagram representing a A'ertical Section of the Placenta. (After Dalton.) . 117 

63. Diagram illustrating the Mode in which a Placental Villus derives a Cover- 

ing from the Vascular System of the Mother. (After Priestley.) .... 117 

64. The Extremity of a Placental Villus. (After Goodsir.) 117 

65. Anterior and Posterior Fontanelles 124 



ILL USTRA TIONS. x x ill 

PIG. PAGE 

66. Bi-parietal diameter, Sagittal and Lambdoidal Sutures, with Posterior F'on- 

tanelle 124 

67. Diameters of the Foetal Skull 125 

68. Mode of Ascertaining the Position of the Foetus by Palpation 127 

69. Diagram illustrating the Effect of Gravity on the Foetus. (After Duncan. j 129 

70. Illustrating the greater Mobility of the Foetus and the larger relative amount 

of Liquor Amnii in Early Pregnancy. (After Duncan. j 129 

71. Diagram of Foetal Heart. (After Dalton.) 133 

72. Diagram of Heart of Infant. (After Dalton.) 134 

73. Relations of Pregnant Uterus at six months. (After Martin.) 137 

74. Size of Uterus at Various Periods of Pregnancv 138 

76. I Supposed Shortening of the Cervix at the third, sixth, eighth, and ninth 

77- j months of Pregnancy, as fignred in Obstetric AVorks 140 

78. J 

79. Cervix of a Woman Dying in the Eighth Month of Pregnancy. (After 

Duncan.) 140 

80. Appearance of the Areola in Pregnancy 151 

81. Illustrating the Cavity between the Decidua Vera and the Decidua Reflexa 

during the early Months of Pregnancy. (After Coste.) 175 

82. Tubal Pregnancy, with the Corpus Luteum in the Ovary of the opposite side 179 

83. Tubal Pregnancy. (From a specimen in the Museum of King's College.) . 180 

84. Extra-uterine Pregnancy at term of the Tubo-ovarian Variety. (After a 

case of Dr. A. Sidney Campbell's.) 182 

85. Uterus and Foetus in a case of Abdominal Pregnancy 187 

86. Lithopsedion. (From a preparation in the Museum of the Royal College 

of Surgeons.) 188 

87. Contents of the Cyst in Dr. Oldham's case of Missed Labor 194 

88. Hypertrophied Decidua laid open, with the Ovum attached to its Fundal 

Portion. (After Duncan.) 229 

89. Imperfectly developed Decidua Vera, with the Ovum. (After Duncan.) . . 230 

90. Hydatidiform Degeneration of the Chorion 232 

91. Myxoma Fibrosum of the Placenta. (After Storch.) 235 

92. Double Placenta, with Single Cord 236 

93. Fatty Degeneration of the Placenta 237 

94. Knots in the Umbilical Cord 238 

95. Intra-uterine Amputation of both Arms and Legs 244 

96. An Apoplectic Ovum, with Blood effused in masses under the Fcetal Surface 

of the Membranes 249 

97. Blighted Ovum, with Fleshy Degeneration of the Membranes 250 

98. Mode in which the Placenta is Naturally Expelled. (After Duncan.) . . 270 

99. Attitude of Child in First Position. (After Hodge.) • . 275 

100. First Position : Movement of Flexion 275 

101. FiiNt Position: Occiput in Cavity of Pelvis. (After Hodge.) 277 

102. First Position : Occiput at Outlet of Pelvis. (After Hodge. ) 278 

103. First Position : Head Delivered. (After Hodge.) 279 

104. External Rotation of Head in First Position, (.\ftor Hodge.) 280 

105. Third Position of Occiput at Brim of Pelvis 281 

106. Fourth Position of Occiput at Pelvic Brim 283 

107. Examination during the First Stage of Labor 288 

108. Mode of EU'ecting Relaxation of the Perineum 292 

109. Usual INIethod of Retnoving the Placenta by Traction on the Cord . . 296 

110. Illustrating Expression of the Placenta 297 

HI. First, or left Sacro-anterior Position of the lUvoch 308 



xxiv ILL USTRA TIONS. 

FIG. PAGE 

112. Passage of the Shoulders and Partial Rotaiion of the Thorax 308 

113. Descent of the Head 309 

li4. Third Position in Face Presentation 318 

115. Rotation forward of Chin 319 

116. Passage of the Head through the External Parts in Face Presentation . . 320 

117. Illustrating the Position of the Head when Forward Rotation of the Chin 

does not take place 321 

118. Dorso-anterior Presentation of the Arm 329 

119. Dorso-posterior Presentation of the Arm 329 

120. Spontaneous Evolution. (After Chiara.) 334 

121. Dorsal Displacement of the Arm 337 

122. Dorsal Displacement of the Arm in Footling Presentation. (After Barnes.) 337 

123. Prolapse of the Umbilical Cord 338 

124. Postural Treatment of Prolapse of the Cord 340 

125. Braun's Apparatus for Replacing the Cord 341 

126. Labor Complicated by Ovarian Tumor 365 

127. Twin Pregnancy, Breech and Head Presenting 370 

128. Head Locking, both Children presenting Head first. (After Barnes.) . . . 372 

129. Head Locking, first Child coming Feet first: Impaction of Heads from 

wedging in Brim. (After Barnes.) 373 

130. Labor impeded by Hydrocephalus 378 

131. Adult Pelvis retaining its Infantile Type 385 

132. Scolio-Rachitic Pelvis 386 

133. Rickety Pelvis, with Backward Depression of Symphysis Pubis 387 

134. Flatness of Sacrum, with Narrowing of Pelvic Cavity 388 

135. Pelvis Deformed by Spondyl-olisthesis. (After Kilian.) 388 

136. [Spondyl-olisthesis. (After Neugebauer.)] 389 

137. Osteomalacic Pelvis 391 

138. Extreme Degree of Osteomalacic Deformity 391 

139. Obliquely-Contracted Pelvis. (After Duncan.) 392 

140. Kyphotic Pelvis 393 

141. Robert's, or Double Obliquely-Contracted Pelvis. (After Duncan.) . . . . 393 

142. Bony Growth from Sacrum obstructing the Pelvic Cavity 394 

143. Head passing through the Inlet in Flat Pelvis. (After Par vin.) 397 

144. Marked Flexion of the Head entering a Generally-Contracted Pelvis. (After 

Parvin.) 397 

145. Greenhalgh's Pelvimeter 399 

146. Section of Foetal Cranium, showing its Conical Form 402 

147. Showing the Greater Breadth of the Biparietal Diameter of the Foetal 

Cranium. (After Simpson.) 402 

148. Showing the Greater Space for the Biparietal Diameter at the side of the 

Pelvis in certain Cases of Deformity. (After Simpson.) 403 

149. Irregular Contraction of the Uterus, with Encystment of the Placenta . . . 425 

150. Illustrating the Dangerous Thinning of the Lower Segment of Uterus, 

owing to Non-descent of Head in a case of Intra-uterine Hydrocephalus. 

(After Bandl.) 44I 

151. Partial Inversion of the Fundus 450 

152. Illustrating the Commencement of Inversion at the Cervix. (After Duncan.) 452 

153. Barnes Bag for Dilating the Cervix 460 

154. First Stage of Bipolar Version. (After Barnes.) • 470 

155. Second Stage of Bipolar Version. (After Barnes.) 471 

156. Third Stage of Bipolar Version. (After Barnes.) 471 

157. Fourth Stage of Bipolar Version. (After Barnes.) 472 

158. Seizure of the Feet when the Hand is Introduced into the Uterus .... 473 



ILL USTBA TIONS. xxv 

FIO. PAGf: 

159. Drawing Down of the Feet and Completion of Version 474 

160. Showing the Completion of Version. (After Earnes.j 47-5 

161. Showing the use of the Eight Hand in Abdomino-anterior Positions . . . 476 

162. Denman's Short Forceps 479 

163. Ziegler's Forceps 480 

164. Simpson's Forceps 481 

165. Tarnier's Forceps 482 

166. Simpson's Axis-Traction Forceps 483 

167. Position of Patient for Forceps Delivery, and Mode of Introducing the 

Lower Blade 486 

168. Introduction of the Upper Blade 488 

169. Forceps in Position ; Traction in the Axis of the Brim, Downward and 

Backward 488 

170. Last Stage of Extraction ; the Handles of the Forceps turned Upward to- 

ward the Mother's Abdomen 489 

171. [Hodge Forceps] 495 

172. [Wallace Forceps] 495 

173. [Davis Forceps] 495 

174. [Elliott Forceps] 496 

175. [Sawyer Forceps] 496 

176. [Application of the Forceps at the Inferior Strait] 498 

177. [Application of the Forceps with the Head at the Superior Strait, the Left 

Blade held in place by an Assistant] 499 

178. [Direction of the Forceps as the Head is being Delivered] 500 

179. Vectis with Hinged Handle 502 

180. Wilmot's Fillet 503 

181.^ 

182. I Various Forms of Perforators 505 

183.) 

Crochets 506 



185 

186. Craniotomy Forceps 507 

187. Simpson's Cranioclast 507 

188. Hicks' Cephalotribe 50S 

189. Perforation of the Skull 511 

190. Foetal Head Crushed by Cephalotribe 514 

191. Professor Simpson's Basilyst 515 

192. [Meigs' Straight Craniotomy Forceps] 516 

193. [Meigs' Curved Craniotomy Forceps] 516 

194. Method of Transfusion by Aveling's Apparatus 545 

195. Shiifer's Canula for Immediate Transfusion 546 

196. Section of a LTterine Sinus from the Placental Site Nine Weeks after De- 

livery. (Y^fterWillianis.) 556 

197. Plan of Bedroom with I^nsanitary Arrangements COS 

198. Plan of Bedroom and Dressing-room to illustrate Case 2 609 

616 



199 
200 
201 



617 
618 



202. rTemperature Charts \ 619 

203. 620 

204. 621 
205.1 . [g23 

206. Hayes' Tube for Intra-uterine Injections 62" 

207. Temperature Chart 624 



PLATE J. 



Duodenum 
Pancreas 




Ob Pub^:^ 



Bladder- 



Clitoris^ 



5EC1'I0X OK A FROZEN BODY IN THE LAST MONTH OF PREGNANCY (aFTEB BKAUSE), ILLLSTKATING THE 

RELATIONS OF THE L'TEUUS TO THE 8URR0VND1NG PARTS, AND THE ATTITUDE OF THE 

FflRTl'S, WHICH IS LYING IN THE SECOND CRANIAL POSITION. 



I 



PLATE II 



Pancreas 



^4 Sup. Mcscnt 

4A — ^-V.Portjr, 




Ext. Os Uteri 



Urethra 



Ext. Os Uteri 



Rectum 



I.iqnor AuiniL 



SKCTION OF A KUOZKN llODY AT TlIK TEUSIINATlON OK THK FIRST STAGE OF I.ABOIJ (aFTEI! IIRAVNKI 

TlIF, IIAC OK MEMIIKANIJS IS STII.I, I'XIUIOKK.V, TlIK CERVIX IS FlLl.Y IMLATEO. AM> 

THE UKAU (^IN THE SK(OM> »'OSITHiN~) IS IN THE I'ELVIC ^AVII^. 



THK 

SCIENCE AND PRACTICE 

OF 

MIDWIFERY. 



PART I. 



ANATOMY AND PHYSIOLOGY OF THE ORGANS 
CONCERNED IN PARTURITION. 



CHAPTER I. 

ANATOMY OF THE PELVIS. 

The pelvis is the bony basin situated between the trunk and the 
lower extremities. To the obstetrician its study is of paramount im- 
portance^ for it not only contains, in the unimpregnated state, all the 
organs connected with the function of reproduction, but through its 
cavity the foetus has to pass in the process of parturition. An accurate 
knowledge, therefore, of its anatomical formation may be said to be the 
very alphabet of obstetrics, without Avhich no one can practise midwifery, 
either with satisfaction to himself or safety to his patient. 

In a treatise on obstetrics, however, any detailed account of the purely 
descriptive anatomy of i\\Q pelvis would be out of place. A knowledge 
of that must be taken for granted, and it is only necessary to refer to 
those points which have a more or less direct bearing on the study of 
its obstetrical relations. 

The pelvis is formed of four bones. On either side are the o.>?o?(7 
innomimda, joined together by the sacrum; to the inferior extremity 
of the sacrum is attaclied the cocGyx, which is, in fact, its continuation. 

The OS innominatum (Fig. 1) is an irregularly-shaped bone origi- 
nally formed of three distinct portions, the ilium , the ischium, and the 
pubcs, which remain separated from each other up to and beyond the 
p(n-iod of })uberty. They are united at the acetabulum by a Y-shnptxl 
cartilaginous junction, which does not, as a rule, become ossitied until 
about the twentieth year.' The consequence is that the pelvis, during 
the period of growth, is subject to the action oi' various mechanical 
3 3:> 



34 OBGAXS CONCERXED IN PARTURITION. 

influences to a far greater extent than in adult life ; and these, as we 
shall presently see, have an important effect in determining the form of 
the bones. The external surface and borders of the os innominatum 
are chiefly of obstetric interest from giving attachment to muscles, 

Fig. 1. 




Os Innominatum. 

many of which have an important accessory influence on parturition, 
such as the muscles forming the abdominal wall, which are attached to 
its crest, and those closing its outlet and forming the perineum, which 
are attached to the tuberosity of the ischium. On the anterior and 
posterior extremities of the crest of the ilium are two prominences (the 
anterior and . posterior spinous processes), which are points from which 
certain measurements are sometimes taken. The internal surface of the 
upper fan-shaped portion of the os innominatum gives attachment to 
the iliacus muscle, and contributes to the support of the abdominal con- 
tents : along with its fellow of the opposite side it forms ihe false pelvis. 
The false is separated from the true pelvis by the ilio-pectineal line, 
which, with the upper margin of the sacrum, forms the brim of the 
pelvis. This is of special obstetric importance, as it is the first part of 
the pelvic cavity through which the child passes, and that in which 
osseous deformities are most often met with. At one portion of the 
ilio-pectineal line, corresponding with the junction of ilium and pubes, 
is situated a prominence which is known as the ilio-pectineal emi- 
nence. 

The internal smooth surface of the innominate bone below the linea 
ilio-pectinea forms the greater portion of the pelvis proper. In front, 
with the corresponding portions of the opposite bone, it forms the arch 
of the pubes, under which the head of the child passes in labor. 

Behind this we observe the oval obturator foramen, and below that 
the tuberosity and spine of the ischium, the latter separating the great 
and lesser sciatic notches and giving attachment to ligaments of import- 
ance. The rough articulating surface posteriorly, by which the junc- 
tion with the sacrum is effected, may be noted, and above ^Jiis the 



ANATOiMY OF THE PELVIS. 



35 



Fig. 2. 




Sacrum and Coccyx. 



prominence to which the powerful ligaments joining the sacrum and 
OS innominatum are attached. 

The sacrum (Fig. 2) is a triangular and somewhat spongy bone 
forming the continuation of the spinal column and binding together the 
ossa innominata. It is originally com- 
posed of five separate portions, analogous 
to the vertebrae, which ossify and unite 
about the period of puberty, leaving on 
its internal surface four prominent ridges 
at the points of junction. The upper of 
these is sometimes so well marked as to be 
mistaken, on vaginal examination, for the 
promontory of the sacrum itself. 

The base of the sacrum is about 4J 
inches in width, and its sides rapidly ap- 
proximate until they nearly meet at its 
apex, giving the whole bone a triangular 
or wedge shape. The anterior and pos- 
terior surfaces also approximate in the 
same way, so that the bone is much 
thicker at the base than at the apex. 
The sacrum, in the erect position of the 
body, is directed from above downward 
and from before backward. At its upper edge it is joined, the lumbo- 
sacral cartilage intervening, with the fifth lumbar vertebra. The point 
of junction, called the promontory of the sacrum, is of great import- 
ance, as on its undue projection many deformities of the brim of the 
pelvis depend. The anterior surface of the bone is concave and 
forms the curve of the sacrum, more marked in some cases than 
in others. There is also more or less concavity from side to side. On 
it w^e observe four apertures on each side, the intervertebral foramina, 
giving exit to nerves. The posterior surface is convex, rough and irreg- 
ular for the attachment of ligaments and muscles, and shoAving a ridge 
of vertical prominences corresponding to the spinous processes of the 
vertebrae. 

The sac^rum is generally described as forming a keystone to the arch 
constituted by the pelvic bones, and transmitting the weight of the body, 
in consequence of its wedge-like shape, in a direction which tends to 
thrust it downwau'd and backward, as if separating the ossa innomi- 
nata. Dr. Duncan,^ however, has shown, from a careful consideration 
of its mechanical relations, that it should rather be regarded as a strong 
transverse beam curved on its anterior surfiice, the extremities of whicli 
are in contact with the corres})onding articular surfaces of the ossa 
innominata. The weight of the body is thus transmitted to the 
innominate bones, and through them to the acetabula and the femora 
(Fig. 3\ There counter-pressure is a})plied, and the result is, as we 
shall subse(]uently see, an important moditying intluence on tlio tlevelop- 
ment and sliai)e of the pelvis. 

The coccyx (Fig. -) is composed of four small separate hones, which 
' Ii(\<earcfu\< in Obshtrii\<. p. (>7. 



36 OBGANS CONCERNED IN PARTURITION. 

eventually unite into one^ but not until late in life. The uj^permost of 
these articulates with the apex of the sacrum. On its posterior surface 
are two small cornua, which unite with corresponding points at the tip 
of the sacrum. The bones of the coccyx taper to a point. To it are 
attached various muscles which have the effect of imparting consider- 

FiG. 3. 




Section of Pelvis and Heads of Thigh-bones, showing the suspensory action of the sacro-iliac 

ligaments. (After Wood.) 

able mobility. During labor, also, it yields to the mechanical pressure 
of the presenting part, so as to increase the antero-posterior diameter 
of the pelvic outlet to the extent of an inch or more. 

If, through disease or accident, as sometimes happens, the articular 
cartilages of the coccyx become prematurely ossified, the enlargement of 
the pelvic outlet during labor may be j^revented, and considerable diffi- 
culty may thus arise. This is most apt to happen in aged primiparse 
or in women who have followed sedentary occupations; and not infre- 
quently, under such circumstances, the bone fractures under the pressure 
to which it is subjected by the presenting part. 

Pelvic Articulations. — The pelvic bones are firmly joined togetlier 
by various articulations and ligaments. The latter are arranged so as to 
complete the canal through which the foetus has to pass, and which is 
in great part formed by the bones. On its internal surface, where the 
absence of obstruction is of importance, they are every way smooth ; 
Avhile externally, where strength is the desideratum, they are arranged 
in larger masses, so as to unite the bones firmly together. The pelvic 
articulations have been generally described as symphyses or amphiar- 
throdia — a term which is properly applied to two articulating surfaces 
united by fibrous tissue in such a way as to prevent any sliding motion. 
It is certain, however, that this is not the case ^vith the joints of the 



ANATOMY OF THE PELVIS. 37 

female pelvis during pregnancy and parturition. Lenoir found that in 
22 females between the ages of eighteen and thirty-five there was a dis- 
tinct sliding motion. Therefore, the pelvic articulations are, strictly 
speaking, to be considered exauiples of the class of joints termed 
arthrodia. 

Lumbo-sacral Joint. — The last lumbar vertebra is united to the 
sacrum by ligamentous union similar to that which joins the verteln'se 
to each other. The intervening fibro-cartilage forms a disk whicli is 
thicker in front than behind, and this, in connection with a similar 
peculiarity of the fifth lumbar vertebra, tends to increase the sloped 
position of the sacrum and the angle which it forms with the vertebral 
column. It constitutes the most prominent portion of the promontory 
of the sacrum, and is the part on which the finger generally impinges 
in vaginal examinations. The anterior common vertebral ligament 
passes over the surface of the joints, and we also find the ligamenta 
subflava and the interspinous ligaments, as in the other vertebne. The 
articular processes are joined together by a fibrous capsule, and there 
is also a peculiar ligament, the lumbo-sacral, extending from the trans- 
verse process of the vertebra on each side, and attaching itself to the 
sides of the sacrum and the sacro-iliac synchondroses. 

Ligaments of Coccyx. — The sacrum is joined to the coccyx, and, 
in some cases at least, the separate bones of the coccyx to each other, by 
smallcartilao-inous disks like that connectinp; the sacrum with the last 
lumbar vertebra. They are further united by anterior and posterior 
common ligaments, the latter being much the thicker and more marked. 
In the adult female a synovial membrane is found between the sacrum 
and coccyx, and it is supposed that this is formed under the influence 
of the movements of the bones on each other. 

Sacro-iliac Synchondrosis. — The opposing articular surfaces of the 
sacrum and ilium are each covered by cartilages, that of the sacrum 
being the thicker. These are firmly united, but in the female, accord- 
ing to Mr. Wood/ they are always more or less separated by an inter- 
vening synovial membrane. Posterior to these cartilaginous convex 
surfaces there are strong interosseous ligaments passing directlv from 
bone to bone, filling up the interspace between them and uniting them 
firmly. There are also accessory ligaments, such as the superior and 
anterior sacro-iliac, which are of secondiiry consequence. The posterior 
sacro-iliac ligaments, however, are of great obstetric importance. They 
are the very strong attachments which unite the rough surfaces on the 
posterior iliac tuberosities to the posterior and lateral surfaces of the 
sacrum. They ])ass obliquely downward from the former points, and 
suspend, as it were, the sacrum from them. According to Duncan, tlie 
sacrum has nothing to })revent its being depressed by the weight o\' the 
body but these ligaments, and it is mainly through them that the weight 
of the body is transmitted to the sacro-cotyloid beams and the heads oi' 
the femora. 

The sacro-sciatic lig-anients are instrumental in eompletino- the 
canal of the pelvis. The 'greater sacro-seiatie ligament is attaeh(\l bv a 
broad base to the posterior- inferior spine ot* tlie ilium, and Xo the pws- 

' Todd's Ci/clopa'dia of Amxtoimj and F/n/sioloQU, aniclo " rdvis." p. I'lS. 



38 OEGASS COXCERyED Z.Y PARTURITION. 

terior surfaces of the sacrum and coccyx. Its fibres unite into a thick 
Corel, cross each other in an X-like manner, and again expand at their 
insertion into the tuberosity of the ischium. The lesser sacro-sciatic 
ligament is also attached with the former to the back parts of the sacrum 
and coccyx, its fibres passing to their much narrower insertion at tlie 
spine of the ischium, and converting the sacro-sciatic notch into a com- 
plete foramen. 

The obturator menibrane is the fibrous aponeurosis that closes the 
large obturator foramen. Joulin^ supposes that, along with the sacro- 
sciatic ligaments, it may, by yielding somewhat to the pressure of the 
foetal head, tend to prevent the contusion to which the soft parts Avould 
be subjected if they were compressed between two entirely osseous sur- 
faces. 

Symphysis Pubis. — The junction of the pubic bones in front is 
effected by means of two oval plates of fibro-cartilage attached to each 
articular surface by nipple-shaped projections, which fit into correspond- 
ing depressions in the bones. There is a greater separation between the 
bones in front than behind, where the numerous fibres of the cartilagi- 
nous plates intersect and unite the bones firmly together. At the upper 
and back part of the articulation there is an interspace between the car- 
tilages whicli is lined by a delicate membrane. In pregnancy this space 
often increases in size, so as to extend even to the front of the joint. 
The juncture is further strengthened by four ligaments — the anterior, 
the posterior, the superior, and the subpubic. Of these, the last is the 
largest, connecting together the pubic bones and forming the upper 
boundary of the pubic arch. 

Movements of Pelvic Joints. — The close apposition of the bones 
of the pelvis might not unreasonably lead to the supposition that no 
movement took place between its component parts; and this is the 
opinion which is even yet held by many anatomists. It is tolerably 
certain, however, that even in the unimpregnated condition there is a 
certain amount of mobility. Thus, Zaglas has pointed out^ that in man 
there is a movement in an antero-posterior direction of the sacro-iliac 
joints which has the effect, in certain positions of the body, of causing 
the sacrum to project downward to the extent of about a line, thus 
narrowing the pelvic brim, tilting up the point of the bone, and 
thereby enlarging the outlet of the pelvis. This movement seems 
habitually brought into play in the act of straining during defeca- 
tion. 

During pregnancy in some of the lower animals there is a very 
marked movement of the pelvic articulations which materially facili- 
tates the process of parturition. This, in the case of the guinea-jjig 
and cow, has been especially pointed out by Dr. Matthews Duncan.^ 
In the former, during labor, the pelvic bones separate from each other 
to the extent of an inch or more. In the latter the movements are 
different, for the symphysis pubis is fixed by bony ankylosis, and is im- 
movable; but the sacro-iliac joints become swollen during pregnancy, 

^ Tmite d^ Accouchement s, p. 11. 

2 Monthly Journal of Medical Science, Sept., 1851. 

^ Researches in Obstetrics, p. 19. 



ANAT03IY OF THE PELVIS. 39 

and extensive movements in an antero-posterior direction take place in 
them which materially enlarge the pelvic canal during, labor. 

It is extremely probable that similar movements take place in 
women, both in the symphysis pubis and in the sacro-iliac joints, 
although to a less marked extent. These are particularly well 
described by Dr. Duncan. They seem to consist chiefly in an ele- 
vation and depression of the symphysis pubis, either by the ilia 
moving on the sacrum, or by the sacrum itself undergoing a forward 
movement on an imaginary transverse axis passing through it, thus 
lessening the pelvic brim to the extent of one or even two lines, and 
increasing, at the same time, the diameter of the outlet by tilting up 
the apex of the sacrum. These movements are only an exaggeration of 
those which Zaglas describes as occurring normally during defecation. 
The instinctive positions which the parturient woman assumes find an 
explanation in these observations. During the first stage of labor, 
when the head is passing through the brim, she sits or stands or walks 
about, and in these erect positions the symphysis pubis is depressed and 
the brim of the pelvis enlarged to its utmost. As the head advances 
through the cavity of the pelvis she can no longer maintain her erect 
position, and she lies down and bends her body forward, which has the 
effect of causing a nutatory motion of the sacrum, with corresponding 
tilting up of its apex, and an enlargement of the outlet. 

These movements during parturition are facilitated by the changes 
which are known to take place in the pelvic articulations during preg- 
nancy. The ligaments and cartilages become swollen and softened, 
and the synovial membranes existing between the articulating surfaces 
become greatly augmented in size and distended with fluid. These 
changes act by forcing the bones apart, as the swelling of a sponge 
placed between them might do after it had imbibed moisture. The 
reality of these alterations receives a clinical illustration from those 
cases which are far from uncommon in which these chans^es are carried 
to SO extreme an extent that the power of progression is materially 
interfered with for a considerable time after delivery. 

On looking at the pelvis as a Avhole we are at once struck with its 
division into the true and false pelvis. The latter portion (all that is 
al)ove the brim of the pelvis) is of comparatively little obstetric 
importance, except in giving attachments to the accessory muscles of 
parturition, and need not be further considered. The brim of the pel- 
vis is a heart-shaped opening bounded by the sacrum behind, the linea 
ilio-pectinea on either side, and the symphysis of the pubes in front. 
All below it forms the cavity, which is bounded by the hollow of the 
sacrum behind, by the inner surfaces of the innominate bones at the 
sides and in front, and by the posterior surface of the symphysis pubis. 
It is in this })art of tho pelvis that the changes in direction which the 
f(X)tal head undergoes in labi^rare imparted to it. The lower border of 
this canal or pelvic outlet (Fig. 4) is lozenge-shaped — is bounded bv the 
lschiati(^ tuberosities on either side, the tip oi^ the coccyx behind, and 
the under surface of the pubic symphysis in front. Posteriorly to 
the tuberosities of the Ischia the boundaries ot' the outlet are com- 
pleted by the sacro-seiatic ligaments. 



40 



OEGAXS COyCEEXED IX PAETURITIOX. 



There is a verv marked dilfereDce between the pelvis iu the male 
and the female, and the peculiarities of the latter all tend to facilitate the 
process of parturition. In the female pelvis (Fig. 5) all the bones are 



Fig. -i. 




Outlet of Pelvis, 

lighter in structure, and have the points for muscular attachments 
much less developed. The iliac bones are more spread otit, hence the 
greater breadth which is observed in the female figure, and the peculiar 
side-to-side movement which all females have in walking. The tuber- 
osities of the ischia are lighter in structm-e and farther apart, and the 
rami of the pubes also converge at a much less acute ano^le. This 
greater breadth of the pubic arch gives one of the most easilv appreciable 
points of contrast between the male and the female pelvis : the pubic arch 

Fig. 5. 




The Female Pelvis. 



in the female forms an angle of from 90° to 100°, while in the male 
(Fig. 6) it averages from 70° to 75°. The obturator foramina are 
more triangular in shape. 

The whole cavit}' of the female pelvis is wider and less funnel- 
shaped than in the male, the symphysis pubis is not so deep, and, as 
the promontory of the sacrum does not project so much, the shape of 



ANATOMY OF THE PELVIS. 



41 



the pelvic brim is more oval than in the male. These differences 
between the male and female pelvis are probably due to the presence 
of the female genital organs in the true pelvis, the growth of which 



Fig. 6. 




The Male Pelvis. 

increases its development in width. In proof of this, Schroeder states 
that in women with congenitally defective internal organs, and in 
women who have had both ovaries removed early in life, the pelvis 
has always more or less of the masculine type. 

The Hieasureraents of the pelvis that are of most importance 
from an obstetric point of view are taken between various points 
directly opposite to each other, and are known as the diameters of the 
pelvis. Those of the true pelvis are the diameters which it is especi- 
ally important to fix in our memories, and it is customary to describe 
three in works on obstetrics — the antero-posterior or conjugate, the 

Fig. 7. 




Brim of Pelvis, showing antero-posterior, c. v, oblique, p, and transverse, T, diameters. 

oblique, and the transverse — although of course the moasuronionts 
may be taken at any op}K)sing points in the circumference of the bones. 
The (nitero-posferior (diameter co)}Ji((/afa rcra, o, v, fiacro-puhic) at the 
brim (Fig. 7) is taken from the upper part oi' the posterior surface ot' 



42 



OBGANS CONCERNED IN PARTVBITION. 



the symphysis pubis to the centre of the promontory of the sacrum ; 
in the cavity, from the centre of the symphysis pubis to a correspond- 
ing point in the body of the third piece of the sacrum; and at the 
outlet (coccy-pubic), from the lower border of the symphysis pubis to 
the tip of the coccyx. The oblique (diameter diagonalis, b), at the 
brim, is taken from the sacro-iliac joint on either side to a point of the 
brim corresponding with the ilio-pectiueal eminence (that starting from 
the right sacro-iliac joint being called the right oblique [diameter diag- 
onalis dextra, D. d], that from the left, the left oblique [diameter diag- 
onalis sinistra, D. s]) ; in the cavity a similar measurement is made at 
the same level as the conjugate ; while at the outlet an oblique diameter 
is not usually measured. The transverse (diameter transversa, t) is 
taken at the brim, from a point midway between the sacro-iliac joint 

and the ilio-pectineal eminence to a 
YiQ. 8. corresponding point at the opposite 

side of the brim ; in the cavity 
from points in the same plane as 
the conjugate and oblique diam- 
eters ; and at the outlet from the 
centre of the inner border of one 
ischial tuberosity to that of the 
other. The measurements given by 
various writers differ considerably 
and vary somewhat in different 
pelves. Taking the average of a 
large number, the following may 
be given as the standard measure- 
ments of the female pelvis : 




Brim . 
Cavity 
Outlet 



Antero- 
posterior, 
C.V. 
in. 

4.25 

4.7 

5.0 





Trans- 


Oblique, 


verse, 


D. 


T. 


in. 


in. 


4.8 


5.2 


5.2 


4.75 


. . 


4.2 



It will be observed that the 
lengths of the corresponding diam- 
eters at different places vary 
greatly ; thus, w^hile the transverse 
(t) is longest at the brim, the 
oblique (d) is longest in the cav- 
ity, and the antero-posterior at the 
outlet. It will be subsequently 
seen that this fact is of great prac- 
tical importance in studying the 
mechanism of delivery, for the 
head in its descent through the 
pelvis alters its position in such a 
way as to adapt itself to the longest 
diameter of the pelvis ; thus, as it 
passes through the cavity it lies in the oblique (d) diameter, and 



Section of Pelvis, showing the diameters. 



ANATOMY OF THE PELVIS. 43 

then rotates so as to be expelled in the antero-posterior (c. v) diam- 
eter of the outlet. 

In thinking of these measurements of the pelvis it must not be 
forgotten that they are taken in the dried bones, and that they are 
considerably modified during life by the soft parts. This is especi- 
ally the case at the brim, where the projection of the psoas and 
iliacus muscles lessens the transverse (t) diameter about half an inch, 
while the antero-posterior (c. v) diameter of the brim and all the 
diameters of the cavity are lessened by a quarter of an inch. The 
right oblique diameter (d. d) of the brim is, even in the dried pelvis, 
found to be on an average slightly longer than the left (d. s), probably 
on account of the increased development of the right side of the pelvis 
from the greater use made of the right leg ; but, in addition to this, 
the left oblique diameter (d. s) is somewhat lessened during life by 
the presence of the rectum on the left side. The advantage gained 
by the comparatively frequent passage of the head through the pel- 
vis in the right oblique diameter (d. d) is thus explained. 

There are one or two other measurements of the true pelvis Avhich 
are sometimes given, but which are of secondary importance. One of 
these, the sacro-cotyloid diameter, is that between the promontory of 
the sacrum and a point immediately above the cotyloid cavity, and 
averages from 3.4 to 3.5 inches. Another, called by Wood the lower or 
inclined conjugate diameter (diameter conjuc/ata diagonalis, c. d), is that 
between the centre of the lower margin of the symphysis pubis and 
the promontory of the sacrum, and averages half an inch more than 
the antero-posterior diameter of the brim. These measurements are 
chiefly of importance in relation to certain pelvic deformities. 

The external measurements of the pelvis are of no real consequence 
in normal parturition, but they may help us in certain cases to estimate 
the existence and amount of deformities. Those which are generally 
given are: Between the anterior-superior iliac spines, 10 inches; 
between the central points of the crests of the ilia, lOJ inches; 
between the spinous process of the last lumbar vertebra and the 
upper part of the symphysis pubis (external conjugate), 7 inches. 

Planes of the Pelvis. — By the planes of the pelvis are meant 
imaginary levels at any portion of its circumference. If we were to 
cut out a piece of cardboard so as to fit the pelvic cavity, and place it 
either at the brim or elsewhere, it would represent the pelvic plane at 
that particular part ; and it is obvious that we may conceive as many 
planes as we desire. Observation of the angle which the pelvic planes 
form with the horizon shows the great obliquity at which the jielvis is 
placed in regard to the spinal column. Thus the angle A r i (Fig. 9) 
represents the inclination to the horizon of the plane of the pelvic 
brim, r b, and is estimated to be about ()0°, while the angle which the 
same plane forms with the vertebral column is al>ont 150''. The plane 
of the outlet forms, with the coccyx in its usual position, an angle witli 
the horizon of about 1 1°, but which varies greatly with the moven\ents 
of the tip of the coccv:^: and the degree to which it is pusluxl back 
during parturition. These figures nuist only be taken as giving an 
approximate idea of the inclination of the pelvis to the spinal i.\)l- 



44 



OEGASS COXCERXED IX PARTURITIOX. 



umn, and it must be remembered that the degree of iDclination varies 
considerably in the same female at different times, in accordance with 
the i^osition of the body. During pregnancy especially the obliquity 
of the brim is lessened by the patient "throwing herself backward in 



Fig. 9. 




Planes of the Pelvis, with Horizon. 

A B. Horizon. c D. Tertical line. 

A B I. Anple of inclination of pehis to horizon, equal to 60°. 

B I c. Angle of inclination of pelvis to spinal column, equal to 150^. 

c I J. Angle of inclination of sacrum to spinal column, equal to 130^. 

E F. Axis of pelvic inlet. l m. Mid-plane in the middle line. 

N. Lowest point of mid-plane of ischium. 



order to support more easily the weight of the gravid uterus. The 
height of the promontory of the sacrum above the upper margin of 
the symphysis pubis is on an average about 3f inches, and a line pass- 
ing horizontally backward from the latter point would impinge on the 
junction of the second and third coccygeal bones. 

Axes of the Parturient Canal. — By the axis of the pelvis is 
meant an imaginary line which indicates the direction which the foetus 
takes during its expulsion. The axis of the brim (Fig. 10) is a line 
drawn perpendicular to its plane, which would extend from the umbil- 
icus to about the apex of the coccyx ; the axis of the outlet of the bony 
pelvis intersects this, and extends from the centre of the promontory of 
the sacrum to midway between the tuberosities of the ischia. The axis 
of the entire pelvic canal is represented by the sum of the axes of an 
indefinite number of planes at different levels of the pelvic cavity, 
which forms an irregular parabolic line, as represented in the accom- 
panying diagram (Fig. 10, A d). 

It must be borne in mind, however, that it is not the axis of the bony 
pelvis alone that is of importance in obstetrics. AVe must always, in 



ANATOMY OF THE PELVIS. 
Fig. 10. 



45 




Axes of the Pelvis. 

A. Axis of superior plane. b. Axis of mid-plane. 

D. Axis of canal. 



c. Axis of inferior plane. 
E. Horizon. 



considering this subject, remember that the general axis of the parturi- 
ent canal (Fig. 11) also includes that of the uterine cavity above and 
of the soft parts below. These are variable in direction according to 



Fig. 11. 




Rcprcscntinjr Gouoral Axis of Part urieiil Canal, iucludiug the Itoriiio Cavitv and Sort Part: 



46 



ORGAXS CONCERNED IN PARTURITION 



circumstances; and it is only the axis of that portion of the par- 
turient canal extending between the plane of the pelvic brim and 
a plane between the lower edge of the pubic symphysis and the 
base of the coccyx that is fixed. The axis of the lower part of the 
canal will vary according to the amount of distension of the perineum 
during labor ; but when this is stretched to its utmost, just before the 
expulsion of the head, the axis of the plane between the edge of the 
distended perineum and the lower border of the symphysis looks nearly 
directly forward. The axis of the uterine cavity generally corresponds 
Avith that of the pelvic brim, but it may be much altered by abnormal 
positions of the uterus, such as anteversion from laxity of the abdomi- 
nal walls. The foetus, under such circumstances, will not enter the 
brim in its proper axis, and difficulties in the labor arise. A know- 
ledge of the general direction of the parturient canal is of great import- 
ance in practical midwifery in guiding us to the introduction of the 
hand or instruments in obstetric operations, and in showing us how to 
obviate difficulties arising from such accidental deviations of the uterus 
as have just been alluded to. 

Cavity of the Pelvis. — The arrangements of the bones in the 
interior of the pelvic canal (Fig. 12) are important in relation to the 
mechanism of delivery. A line passing between the spine of the 

ischium and the ilio-pectineal enii- 
FiG. 12. nence divides the inner surface of the 

ischial bone into two smooth plane sur- 
faces, which have received the name of 
the planes of the ischium. Two other 
planes are formed by the inner surfaces 
of the pubic bones in front and by the 
upper portion of the sacrum behind, 
both having a direction downward and 
backward. In studying t]:ie mechanism 
of delivery it will be seen that many 
obstetricians attribute to these planes, 
in conjunction with the spines of the 
ischia, a very important influence in 
effecting rotation of the foetal head 
from the oblique to the antero-pos- 
terior diameter of the pelvis. 
Development of the Pelvis. — The peculiarities of the pelvis during 
infancy and childhood are of interest as leading to a knowledge of the 
manner in which the form observed during adult life is impressed upon 
it. The sacrum in the pelvis of the child (Fig. 13) is less developed 
transversely and is much less deeply curved than in the adult. The 
pubes is also much shorter from side to side, and the pubic arch is an 
acute angle. The result of this narrowness of both the pubes and 
sacrum is that the transverse (t) diameter of the pelvic brim is 
shorter instead of longer than the antero-posterior (c. y). The sides 
of the pelvis have a tendency to parallelism, as well as the antero-pos- 
terior walls ; and this is stated by AVood to be a peculiar characteristic 
of the infantile pelvis. The iliac bones are not spread out as in adult 




Side View of Pelvis. 



ANATOMY OF THE PELVIS. 47 

life, so that the centres of the crests of the ilia are not more distant 
from each other than the anterior superior spines. The cavity of tlie 
true pelvis is small, and the tuberosities of the ischia are jjroportionately 
nearer to each other than they afterward become; the jiclvic viscera are 
consequently crowded up into the abdominal cavity, wiiich is, for tiiis 
reason, much more prominent in children than in adults. The bones 

Fia. 13. 




Pelvis of a Child. 



are soft and semi-cartilaginous until after the period of puberty, and 
yield readily to the mechanical influences to which they are subjected ; 
and the three divisions of the innominate bone remain separate until 
about the twentieth year. 

As the child grows older the transverse development of the sacrum 
increases, and the pelvis begins to assume more and more of tiie adult 
shape. The mere growth of the bones, however, is not sufficient to 
account for the change in the shape of the pelvis, and it has been Avell 
shown by Duncan that this is chiefly produced by the pressure to whicli 
the bones are subjected during early life. The iliac bones are acted 
upon by two ])rincipal and opposing forces. One is the weight of the 
body above, which acts vertically upon the sacral extrem.ity of the iliac 
beam througli the strong posterior sacro-iliac ligaments, and tends to 
throw the lower or acetabular ends of the sacro-cotyloid beams outward. 
This outward displacement, however, is resisted, partly by the junction 
between the two acetabular ends at the front of the pelvis, but chiefly 
by the opposing force, which is the upward pressure of the lower ex- 
tremities through the femurs. The result of these counteracting forces 
is that the still soft bones bend near their junction with the sacrum, and 
thus the greater transverse^ development of the ])elvic brim character- 
istic of adult life is established. Tn treating the pelvic deformities it 
will be seen that the same forces aj^plied to diseased and sofioneil bones 
explain the ])eculiarities of form that they assume. 

Pelvis in Different Races. — The researches that have boon made on 
the differences of the pelvis in ditVoront races ]>rovo that those are not so 
great as might have been expected. Joulin pointed out that in all 



48 OEGANS CONCERNED IN PARTURITION. 

human pelves the transverse (t) diameter was larger than the antero- 
posterior (c. y), while the reverse was the case in all the lower animals, 
even in the highest simise. This observation has been more recently 
confirmed by Von Franque/ who has made careful measurements of the 
pelvis in various races. In the pelvis of. the gorilla the oval form of 
the brim, resulting from the increased length of the conjugate (c. v) 
diameter, is very marked. In certain races there is so far a tendency 
to animality of type that the difference between the transverse (t) and 
conjugate (c. v) diameters is much less than in European women, but it 
is not sufiiciently marked to enable us to refer any given pelvis to a 
particular race. Von Franque makes the general observation that the 
size of the pelvis increases from south to north, but that the conjugate 
(c. v) diameter increases in proportion to the transverse (t) in southern 
races. 

Soft Parts in Connection with Pelvis. — In closing the description 
of the pelvis the attention of the student must be directed to the mus- 
cular and other structures which cover it. It has already been pointed 
out that the measurements of the pelvic diameters are considerably 
lessened by the soft parts, which also influence parturition in other 
ways. Thus, attached to the crests of the ilia are strong muscles 
which not only support the enlarged uterus during pregnancy, but 
are powerful accessory muscles in labor : in the pelvic cavity are the 
obturator and pyriformis muscles lining it on either side; the pelvic 
cellular tissue and fasciae ; the rectum and bladder ; the vessels and 
nerves, pressure on which often gives rise to cramps and pains during 
pregnancy and labor ; while below the outlet of the pelvis is closed and 
its axis directed forward by the numerous muscles forming the floor of 
the pelvis and perineum. The structures closing the pelvis have been 
accurately described by Dr. Berry Hart,^ who points out that they form 
a complete diaphragm stretching from the pelvis to the sacrum, in 
which are three " faults ^^ or " slits " formed by the orifices of the 
urethra, vagina, and rectum. The first of these is a mere capillary 
slit; the last is closed by a strong muscular sphincter; Avhile the vagina, 
in a healthy condition, is also a mere slit, with its walls in accurate ap- 
position. Hence it follows that none of these apertures impairs the 
structural efficiency of the pelvic floor or the support it gives to the 
structures above it. 

^ Scanzoni's Beitrdge, 1867. 

2 The Structural Anatomy of the Female Pelvic Floor, 



THE FEMALE GENERATIVE ORGANS. 49 



CHAPTER II. 

THE FEMALE GENERATIVE ORGANS. 

The reproductive organs in the female are conveniently dividecl, 
according to their function, into — 1. The external or copulative organs, 
which are chiefly concerned in the act of insemination, and are only of 
secondary importance in parturition : they include all the organs situate 
externally which form the vulva, and the vagina, which is placed inter- 
nally and forms the canal of communication between the uterus and the 
vulva ; 2. The internal or formative organs : they include the ovaries, 
which are the most important of all, as being those in which the ovule 
is formed ; the Fallopian tubes, through which the ovule is carried to 
the uterus ; and the uterus, in which the impregnated ovule is lodged 
and developed. 

1. The external org-ans consist of — 

The mons Veneris (Fig. 14,/), a cushion of adipose and -fibrous 
tissue which forms a rounded projection at the upper part of the vulva. 
It is in relation above with the lower part of the hypogastric region, 
from which it is often separated by a furrow, and below it is continuous 
with the labia majora on either side. It lies over the symphysis and 
horizontal rami of the pubes. After puberty it is covered wdth hair. 
On its integument are found the openings of numerous sweat and 
sebaceous glands. 

The labia majora (Fig. 14, a) form two symmetrical sides to the 
longitudinal aperture of the vulva. They have two surfaces — one ex- 
ternal, of ordinary integument, covered with hair; and another internal, 
of smooth mucous membrane, in apposition with the corresponding 
portion of the opposite labium, and separated from the external sur- 
face by a free convex border. They are thicker in front, Avhere they 
run into the mons Veneris, and thinner behind, where they are united, 
in front of the perineum, by a thin fold of integument called the four- 
chette, which is almost invariably ruptured in the first labor. In the 
virgin the labia are closely in apposition, and conceal the rest of the 
generative organs. After childbearing they become more or less sepa- 
rated from each other, and in the aged they waste and the internal 
nymphse protrude through them. ]>oth their cutaneous and nuicous 
surfaces contain a large number of sebaceous glands, opening either 
directly on the surface or into the hair-follicles. In structure the labia 
are composed of connective tissu(\ containing a varving amount oi' tat, 
and pai'allel with their external sin*tac(^ are ]ilaced tolerably cU^se plex- 
uses of elastic tissue, inters})ersed with regulnrly ;in-;inged smooth nuis- 
cular fibres. These fibres are described by liroca as i'orming a niein- 
branous sac, resembling thq dartos of the scrotum, to which the labia 
majora are analogous. Towaixl its upper and narrcnver entl this sac is 
continuous with the external inguinal ring, and in it terminate some of 



50 



OEGANS COyCEEXED IX PARTURITION. 



the fibres of the rouDcl ligament. The analogy with the scrotum is 
further borne out by the occasional hernial protrusion of the ovary 
into the labium, corresponding to the normal descent of the testis in 
the male. 

The labia minora, or nymphse (Fig. 14, 6), are two folds of mucous 
membrane, commencing below, on either side, about the centre of the 
internal surface of the labium externum; they converge as they proceed 

Fig. 14. 







External Genitals of Virgin with Diaphragmatic Hymen. (After Sappey.) 

s. Labium majus. h. Labium minus, c. Praeputium clitoridis. d. Glans clitoridis. 
e. Vestibule just above urethral orifice. /. Mens Veneris. 



upward, bifurcating as they approach each other. The lower branch 
of this bifurcation is attached to the clitoris (Fig. 14, c), while the 
upper and larger unites with its fellow of the opposite side and forms a 
fold round the clitoris, known as its prepuce. The nymphse are usually 
entirely concealed by the labia majora, but after childbearing and in old 
age they project somewhat beyond them ; then they lose their delicate 
pink color and soft texture, and become brown, dry, and like skin in 
appearance. This is especially the case in some of the negro races, in 
whom they form long projecting folds called the apron. 

The surfaces of the nymphse are covered with tessellated epithelium, 



THE FEMALE GENERATTVE ORGANS. 51 

and over them are distributed a large number of vascular papillae, 
somewhat enlarged at their extremities, and sebaceous glands^ which 
are more numerous on their internal surfaces. The latter secrete an 
odorous, cheesy matter which lubricates the surface of the vulva and 
prevents its folds adhering to each other. The nymphse are composed 
of trabeculse of connective tissue containing muscular fibres. 

The clitoris (Fig. 14, cZ) is a small erectile tubercle situated about 
half an inch below the anterior commissure of the labia majora. It is 
the analogue of the penis in the male, and is similar to it in structure,, 
consisting of two corpora cavernosa, separated from each other by a 
fibrous septum. The crura are covered by the ischio-cavernous muscles, 
which serve the same purpose as in the male. It has also a suspensory 
ligament. The corpora cavernosa are composed of a vascular plexus 
with numerous traversing muscular fibres. The arteries are derived 
from the internal ])udic artery, which gives a branch, the cavernous, to 
each half of the organ ; there is also a dorsal artery distributed to the 
prepuce. According to Gussenbauer, these cavernous arteries pour their 
blood directly into large veins, and a finer venous plexus near the sur- 
face receives arterial blood from small arterial branches. By these 
arrangements the erection of the organ which takes place during sex- 
ual excitement is favored. The nervous su^^ply of the clitoris is large, 
being derived from the internal pudic nerve, which supplies branches to 
the corpora cavernosa, and terminates in the glands and prepuce, where 
Paccinian corpuscles and terminal bulbs are to be found. On this ac- 
count the clitoris has been supposed by some to be the chief seat of 
voluptuous sensation in the female. 

The vestibule (Fig. 14, e) is a triangular space, bounded at its 
apex by the clitoris, and on either side by the folds of the nymphre. 
It is smooth, and, unlike the rest of the vulva, is destitute of sebnceous 
glands, although there are several groups of muciparous glands opening 
on its surface. At the centre of the base of the triangle, which is 
formed by the upper edge of the opening of the vagina, is a prom- 
inence, distant about an inch from the clitoris, on which is the ori- 
fice of the urethra. Tliis prominence can be readily made out by 
the finger, and the depression upon it — leading to the urethra — is of 
importance as our guide in passing the female catheter. This little 
operation ought to be performed without exposing the ])atient, and it is 
done in several ways. The easiest is to place the ti}) of the index 
finger of the left hand (the patient lying on her back) on the apex of 
the vestibule, and slip it gently down until w^e feel the bulb of the 
urethra and the dimple of its orifice, which is generally roadilv found. 
If there is any difficulty in finding the orifice, it is well to ronuMnber 
that it is placcnl imuKHliately below the sharp edge of the lower border 
of the symphysis pubis, wliich will guide us to it. The catheter (and 
a male elastics catheter is always the best, especially during labor, when 
the urethra is apt to be stretched) is then pass(>d under the thigli ot' the 
patient, and directed to the orilice of the urothni by the linger ot' the 
left hand, which is placcnl u]K)n it. \W nnist be t'aret'ul that the 
instrument is really j)ass(Hl into tlie urethra, and not into the vaii'ina. 
It is advisable lo have a tew teet ol' elastic tubino- attat'hed to the end 



52 ORGASS COSCERSED IS PARTURITIOX. 

of the catheter, so that the urine can be passed into a vessel under the 
bed without uncovering the patient. If the patient be on her side in 
the usual obstetric position, the operation can be more readily per- 
formed by placing the tip of the linger in the vagina and feeling its 
upper edge. The orifice of the urethra lies immediately above this, 
and if the catheter be slipped along the palmar surface of the finger it 
can generally be inserted without much trouble. If, however, as is 
often the case during labor, the parts are much swollen, it may be 
difficult to find the aperture, and it is then always better to look for 
the opening than to hurt the patient by long-continued efforts to feel it. 

The tirethra is a canal 1^ inches in length, and it is intimately con- 
nected with the anterior Avail of the vagina, through which it may be 
felt. It is composed of muscular and erectile tissue, and is remarkable 
for its extreme dilatability — a property which is turned to practical 
account in some of the operations for stone in the female bladder. 

About an eighth of an inch above its orifice are the openings of two 
glandular structiu'es situated in its muscular walls. They are about 
three-quarters of an inch in length, and were first described by Pro- 
fessor Skene of Brooklyn.^ 

The orifice of the vagina is situated immediately below the bulb 
of the urethra. In virgins it is a circular opening, but in women who 
have borne children or practised sexual intercourse it is, in the undis- 
tended state, a fissure running transversely and at right angles to that 
between the labia.^ In virgins it is generally more or less blocked up 
by a fold of mucous membrane containing some cellular tissue and 
muscular fibres, with vessels and nerves, which is known as the hymen. 
This is continuous with the anterior extremity of the vagina, the 
mucous membrane of which lines its internal surface, that covering its 
external surface being derived from the mucous membrane of the 
vulva.^ It is most often crescentic in shape, with the concavity of the 
crescent looking upward ; sometimes, however, it is circular with a cen- 
tral opening or cribriform ; or it may even be entirely imperforate, and this 
gives rise to the retention of the menstrual secretion. These varieties 
of form depend on the peculiar mode of development of the fold of 
vaginal mucous membrane which blocks up the orifice of the vagina in 
the foetus, and from Avhich the hymen is formed. The density of the 
membrane also varies in different individuals. ]Most usually it is very 
slight, so as to be ruptured in the first sexual approaches, or even by 
some accidental circumstance, such as stretching tie limbs, so that its 
absence cannot be taken as evidence of want of chastity. A know- 
ledge of this fact is of considerable importance from a medico-legal 
point of view. Sometimes it is so tough as to prevent intercourse alto- 
gether, and may require division by the knife or scissors before this 
can be effected ; and at others it rather unfolds than ruptures, so that it 
may exist even after impregnation has been effected, and it has been 
met with intact in women who have habitually led unchaste lives. In 
a few rare cases it has even formed an obstacle to delivery, and has 
required incision during labor. 

^ Ampr. Jnnrn. of Obstetric^. 1880, vol. xiii. p. 265. ^ Hart. op. cit. 

•* Budin, Recherche.i sur C Hymen et rOrijice vagimiL 1879. 



THE FEMALE GENERATIVE ORGANS. 53 

The carunculse rayrtiformes arc small fleshy tubercles, varying 
from two to five in number, situated round the orifice of the vagina, 
and which are generally su})p()sed to l)e the remains of the ruptured 
hymen. Schroeder, however, maintains that they are only formed after 
childbearing, in consequence of parts of the hymen having been 
destroyed by the injuries received during the passage of the child. 

Vulvo-vag-inal Glands. — Near the posterior part of the vaginal 
orifice, and below the superficial perineal fascia, are situated two con- 
glomerate glands which are the analogues of Cowper's glands ii] the 
male. Each of these is about the size and shape of an almond, and is 
contained in a cellular fibrous envelope. Internally they are of a yel- 
lowish-white color, and are composed of a number of lobules separated 
from each other by prolongations of the external envelope. These 
give origin to separate ducts which unite into a common canal, about 
half an inch in length, which opens in front of the attached edge of 
the hymen in virgins, and in married women at the base of one of the 
carunculse myrtiformes. According to Huguier, the size of the glands 
varies much in different women, and they appear to have some connec- 
tion with the ovary, as he has always found the largest gland to be on 
the same side as the largest ovary. They secrete a glairy, tenacious 
fluid, which is ejected in jets during the sexual orgasm, probably 
through the spasmodic action of the perineal muscles. At other times 
their secretion serves the purpose of lubricating the vulva, and thus 
preserves the sensibility of its mucous membrane. 

Fossa Navicularis. — Immediately behind the hymen, in the 
unmarried, and between it and the perineum, is a small depression 
called the fossa navicularis^ which disappears after childbearing. 

The perineum separates the orifice of the vagina from that of 
the I'cctum. It is about IJ inches in breadth, and is of great olxstetric 
interest, not only as supporting the internal organs from below, but 
because of its action in labor. It is largely stretched and distended by 
the presenting part of the child, and, if unusually tough and unyield- 
ing, may retard delivery, or it may be torn to a greater or less extent, 
thus giving rise to various subsequent troubles. 

Vascular Supply of the Vulva.— The structures described above 
together form the vulva, and they are remarkable for their abundant 
vascular and nervous su})])ly. The former constitutes an erectile tissue 
similar to that which has already been described in the clitoris, and 
which is especially marked about the bulb of the vestibule (Fig. 15). 
From this point, and extending on either side of the vagina, there is a 
well-marked plexus of convoluted veins wliich, in their distended 
state, are likened by Dr. Arthur Farre to a filled leech. The erection 
of* the erectile tissue, as well as that of the clitoris, is brought alnnit 
under excitement, as in the male, by the compression ot' the etVert^nt 
veins, by the contraction of the ischio-cavernous musv'les, ami by that 
of a thin layer of muscular tissues surrounding the orifice t)t' the vagina 
and described as the constrictor vagina\ 

The vag-ina is the canal which foi-ins the communication between 
the external and internal gen.erative (M'gans, thn>ugh which the semen 
passes to reach (he uterus, the miMises llow, and the tonus is oxpenod. 



54 



OEGAXS CONCERNED IN PARTURITION. 



Roughly speaking, it lies in the axis of the pelvis, but its opening is 
placed anterior to the axis of the pelvic outlet, so that its lower jDortiou 
is curved forward so as to lie parallel to the pelvic brim. It is narrow 
below, but dilated above, where the cervix uteri is inserted into it, so 



Fig. 15. 




Vascular Supply of Vulva. (After Kobelt.) 

«. Bulb of A-estibiile. h. Muscular tissue of the vagiua. c, d, e, f. The clitoris and muscles, g, h, i, 
A-, /, }/(, >i. Veins of the nymphce and clitoiis communicating vith the epigastric and obturator veins. 

that it is more or less conoidal in shape. Under ordinary circum- 
stances, especially in the virgin, the .anterior and posterior walls lie in 
close contact Avith each other (see Plate I.), and there is, strictly speak- 
ing, no vaginal canal, although they are capable of wide distension, as 
in copulation and during the passage of the foetus. The anterior Avall 
of the vagina is shorter than the posterior, the former measuring on an 
average 2J inches, the latter 3 inches ; but the length of the canal 
varies greatly in different subjects and under certain circumstances. In 
front, the vagina is closely connected with the base of the bladder, so 
that when the vagina is prolapsed, as often occurs, it drags the bladder 
with it (Fig. 17) ; behind, it is in relation Avith the rectum, but less 
intimately ; laterally, with the broad ligaments and pelvic fascia ; and 
superiorly, with the lower portion of the uterus and folds of perito- 
neum both before and behind. The vagina is composed of mucous, 
muscular, and cellular coats. The mucous lining is thrown into 
numerous folds. These start from longitudinal ridges which exist on 
both the anterior and posterior Avails, but most distinctly on the ante- 
rior. They are A'ery numerous in the young and unmarried, and 
greatly increase the sensitiA^e surface of the vagina (Fig. 16). After 
childbearing and in the aged they become atrophied, but the) never 



THE FEMALE GENERATIVE ORGANS. 
Fig. 16. 



55 




Right Half of Virgin Vagina, with walls held apart, showing the abundant transverse rugse, 
the greater depth of the vagina above than below, and the hymeneal segment. (After 
Hart.) 

completely disappear, and toward the orifice of the vagina, where they 
exist in greatest abundance, they are always to be met with. The 
whole of the mucous membrane is lined with tessellated epithelium. 



Fig. 17. 




Longitudinal Section of Body, >;ho\ving rolat 



10 rat no orc.-ir.'^. 



56 OEGAXS COyCERXED IN PABTUEITIOy. 

and it is covered with a large number of papillae, either conical or 
divided, which are highly vascular and project into the epithelial 
layer. Unlike the vulvar mucous membrane, that of the vagina 
seems to be destitute of glands. Beneath the epithelial layer is a 
submucous tissue containing a large number of elastic and some 
muscular fibres, derived from the muscular walls of the vagina. 
These are strong and well developed, especially toward the ostium vagi- 
nae, where they are arranged in a circular mass having a sphincter 
action. They consist of two layers — an internal longitudinal and an 
external circular — with oblique decussating fibres connecting the two. 
Below they are attached to the ischio-pubic rami, and above they are 
continuous with the muscular coat of the uterus. The muscular tissue 
of the vagina increases in thickness during pregnancy, but to a much 
less degree than that of the uterus. Its vascular arrangements, like 
those of the vulva, are such as to constitute an erectile tissue. The 
arteries form an intricate network around the tube, and eventually end 
in a submucous capillary plexus from which twigs pass to supply the 
papillae ; these again give origin to venous radicles which unite into 
meshes freely interlacing with each other and forming a well-marked 
v^enous plexus. 

2. The internal organs of generation consist of the uterus, the 
Fallopian tubes, and the ovaries; and in connection with them we have 
to study the various ligaments and folds of peritoneum which serve to 
maintain the organs in position, along with certain accessory structures. 
Physiologically, the most important of all the generative organs are the 
ovaries, in which the ovules are formed and which dominate the entire 
reproductive life of the female. The Fallopian tubes, which convey the 
ovule to the uterus, and the uterus itself — whose main function is to 
receive, nourish, and eventually expel the impregnated product of the 
ovary — may be said to be, in fact, accessory to these viscera. Practi- 
cally, however, as obstetricians, we are chiefly concerned with the 
uterus, and may conveniently commence with its description. 

The uterus is correctly described as a pyriform organ, flattened from 
hefore backward, consisting of the body with its rounded fundus, and 
the cervix, which projects into the upper part of the vaginal canal. In 
the adult female it is deeply situated in the pelvis, being placed between 
the bladder in front and the rectum behind, its fundus being below the 
plane of the pelvic brim (Fig. 18). It only assumes the position, how- 
ever, toward the period of puberty, and in the foetus it is placed much 
higher, and lies, indeed, entirely within the cavity of the abdomen. It 
is maintained in this position partly by being slung by its ligaments, 
which Ave shall subsequently study, and partly by being supported 
from below by the pelvic cellular tissue and the fleshy column of 
the vagina. The result is that the uterus, in the healthy female, is 
a perfectly movable body, altering its ])osition to suit the condition of 
the surrounding viscera, especially the bladder and rectum, which are 
subjected to variations of size according to their fulness or emptiness. 
AVhen from any cause — as, for example, some periuterine inflammation 
producing adhesions to the stuTounding textures — the mobility of the 
organ is interfered Avith, nmch distress ensues, and if pregnancy super- 



THE FEMALE GENERATIVE ORGANS. 57 

venes more or less serious consequences may result. Generally speak- 
ing, the uterus may be said to lie in a line roughly corresponding with 
the axis of the pelvic brim, its fundus being pointed forward, and its 
cervix lying in such a direction that a line drawn from it would impinge 

Fig. 18. 




Transverse Section of the Body, showing relations of the fundus uteri. 

m. Pubes. a a (in front). Remainder of hypogastric arteries, a a (behind). Spermatic vessels and nerves. 
B. Bladder. L L. Round ligaments. U. Fundus uteri, t t. Fallopian tubes, o o. Ovaries, r. Rec- 
tum, g. Right ureter, resting on the psoas muscle, c. Utero-sacral ligaments, i'. Last lumbar 
vertebra. 

on the junction between the sacrum and coccyx. According to some 
authorities, the uterus in early life is more curved in the anterior direc- 
tion, and is, in fact, normally in a state of anteflexion. Sappey holds 
that this is not necessarily the case, but that the amount of anterior 
curvature depends ou the emptiness or fulness of the bladder, on which 

Fig. 19. 




Transverse Soction of Uloru^ 



the uterus, as it were, moulds itself in the unimpivgnatod state. It is 
believed also that the bodv-of the uterus is very generally twisttnl some- 
what obli(]uelv, so that its interior siu'taee Kn^ks a little tcnvard the right 
side, this prol)al)ly depending on the presence and tVequent distension 



58 



OEGAXS COXCEBXED IN PARTURITION. 



of the rectum in the left side of the pelvis. The anterior surface of 
the uterus is convex, and is covered in three-fourths of its extent by 
the peritoneum, which is intimately adherent to it. Below the reflec- 
tion of the membrane it is loosely connected by cellular tissue to the 
bladder, so that any downward displacement of the uterus drags the 
bladder along with it. The posterior surface is also convex, but 
more distinctly so than the anterior, as may be observed in looking 
at a transverse section of the organ (Fig. 19). It is also covered by 
peritoneum, the reflection of wliich on the rectum forms the cavity 
known as Douglas' pouch. The fundus is the upper extremity of 
the uterus, lying above the points of entry of the Fallopian tubes. 
It is onlv slightlv rounded in the virgin, but becomes more decid- 
edly and permanently rounded in the woman who has borne chil- 
dren. 

Until the period of puberty the uterus remains small and unde- 
veloped (Fig. 20) ; after that time it reaches the adult size, at which 



Fig. 20. 




uterus and Vppendasre- m an Infant. ^A fter Farre 



it remains until menstruation ceases, when it again atrophies. If the 
woman has borne children it always remains larger than in the nullipara. 
In the viro^in adult the uterus measures 2i inches from the orifice to the 
fundus, rather more than half being taken up by the cervix. Its greatest 
breadth is opposite the insertion of the Fallopian tubes; its greatest 
thickness, about 11 or 12 lines, opposite the centre of its body. Its 
average weight is about 9 or 10 drachms. Independently of preg- 
nancy, the uterus is subject to great altenitions of size toward the men- 
strual period, when, on account of the congestion then present, it 
enlarges, sometimes, it is said, considerably. This fact should be 
borne in mind, as this periodical swelling might be taken for an 
early pregnancy. 

For the purpose of description the uterus is conveniently divided into 



THE FEMALE GENERATIVE ORGANS. 59 

\he fundus, with its rounded upj^cr extremity, situated between the in- 
sertions of the Fallopian tubes ; the body, which is bounded above by 
the insertions of the Fallopian tubes and below by the upper extremity 
of the cervix, and which is the part chiefly concerned in the reception 
and growth of the ovum; and the cervix, which projectsinto the vagina 
and dilates during labor to give passage to the child. The cervix is 
conical in shape, measuring 11 to 12 lines transversely at the base, and 

6 or 7 in the antero-posterior direction ; while at the apex it measures 

7 to 8 transversely and 5 antero-posteriorly. It projects about 4 lines 
into the canal of tlie vagina, the remainder of the cervix being placed 
above the reflection of the vaginal mucous membrane. It varies much 
in form in the virgin and nulliparous married woman and in the Avoman 
who has borne children ; and the differences are of importance in the 
diagnosis of pregnancy and uterine disease. In the virgin it is regu- 
larly pyramidal in shape. At its lower extremity is the oj^ening of the 
external os uteri, forming a small circular opening, sometimes difficult to 
feel, and generally described as giving a sensation to the examining 
finger like the extremity of the cartilage at the tip of the nose. It is 
bounded by two lips, the anterior of which is apparently larger on 
account of the position of the uterus. The surface of the cervix and the 
borders of the os are very smooth and regular. 

In women who have borne children these parts become considerably 
altered. The cervix is no longer conical, but is irregular in form and 
shortened. The lips of the os uteri become fissured and lobulated, on 
account of partial lacerations which have occurred during labor. The 
OS is larger and more irregular in outline, and is sometimes sufficiently 
patulous to admit the tip of the finger. In old age the cervix atro^^hies, 
and after the change of life it not uncommonly entirely disappears, so 
that the orifice of the os uteri is on a level with the roof of the vagina. 

The internal surface of the uterus comprises the cavities of the body 
and cervix — the former being rather less than the latter in length in 
virgins, but about equal in women who have borne children — separated 
from each other by a constriction forming the upper boundary of the 
cervical canal. The cavity of the body is triangular in sliajie, the base 
of the triangle being formed by a line joining the openings of the Fal- 
lopian tubes, its apex by the u})}xn* orifice of the cervix, or internal os, 
as it is sometimes called. In the virgin its boundaries are somewliat 
convex, projecting inward. After childbearing they become straight or 
slightly concave. The opposing surfaces of the cavity are always in 
contact in tlie healthy state, or are only separated from each other bv a 
small quantity of nuicous. 

The cavity of the cervix is spindle-shaped or fusiform, narrower 
above and below at the internal and external os uteri, and somewhat 
dilated between these two points. It is flattened from before backward, 
and its opposing surfiices also lie in contact, but not so closely as tlu>se 
of the body. On the nuicous lining of the anterior and posterior sur- 
faces is a prominent i)erpendi('ular ritlge, with a lesser one at each side, 
from which transverse riclges proceed at more or less acute angles. They 
liave received the name of the arbor vita\ According to (uivon. the 
perj)ondicular ridges are not exactly opposite, so that they tit into each 



60 



ORGANS CONCERNED IN PARTURITION. 



other, and serve more completely to fill up the cavity of the cervix, es- 
pecially toward the internal os (Fig. 21). The arbor vitse is most dis- 
tinct in the virgin, and atrophies considerably after childbeariug. 



Fig. 21. 




Fig. 22. 



Portion of Interior of Cervix, enlarged nine diameters. (After Tyler Smith and Hassall.) 

The superior extremity of the cervical canal forms a narrow isthmus 
separating it from the cavity of the body, and measuring about three- 
eighths of an inch in diameter. Like the external os, it contracts after 
the cessation of menstruation, and in old age sometimes becomes entirely 
obliterated. 

The uterus is composed of tliree principal structures — the peritoneal, 
muscular, and mucous coats. The peritoneum forms an investment to 

the greater part of the organ, extend- 
ing downward in front to the level 
of the OS internum, and behind to 
the top of the vagina, from which 
points it is reflected upward on the 
bladder and rectum respectively. 
At the sides the peritoneal invest- 
ment is not so extensive, for a little 
below the level of the Fallopian 
tubes the peritoneal folds separate 
from each other, forming the broad 
ligaments (to be afterward described) ; 
here it is that the vessels and nerves 
supplying the uterus gain access to it. At the upper part of the organ 
the peritoneum is so closely adherent to the muscular tissue that it can- 
not be separated from it ; below, the connection is more loose. The mass 




IMuscnlar Fibres of Uniinpregnated Uterus. 
(After Farre.) 

a. Filiros united by connective tissue. 

b. Separate fibres and elementary corpuscles. 



THE FEMALE GENERATIVE ORGANS, 61 

of the uterine tissue, both in the body and cervix, consists of unstriped 
muscular fibres (Fig. 22), firmly united together by nucleated connective 
tissue and elastic fibres. The muscular fibre-cells are large and fusiform 
with very attenuated extremities, generally containing in their centreadis- 
tinct nucleus. These (;ells, as well as their nuclei, become greatly enlarged 
during pregnancy (Fig. 23) : according to Strieker, this is only the case 

Fig. 23. 




Developed Muscular Fibres from the Gravid Uterus. (After Wagner.) 

with the muscular fibres which play an important part in the expulsion 
of the foetus, those of the outermost and innermost layers not sharing in 
the increase of size.^ In addition to these developed fibres there are, 
especially near the mucous coat, a number of round elementary corpus- 
cles, which are believed by Dr. Farre^ to be the elementary form of the 
muscular fibres, and which he has traced in various intermediate states 
of development. Dr. John Williams^ believes that a great part of the 
muscular tissue of the uterus — rather more, indeed, than three-fourths 
of its thickness — is an integral part of the mucous membrane, analogous 
to the muscularis mucosae of the mucous membrane of the alimentary 
canal. This he describes as being se]3arated from the rest of the muscu- 
lar tissue by a layer of rather loose connective tissue containing numer- 
ous vessels. In early foetal life and in the uteri of some of the lower 
animals this appearance is very distinct ; In the adult female uterus, 
however, it cannot be readily made out. 

On examining the uterine tissue in an unimpregnated condition no 
definite arrangement of its nuiscular fibres can be made out, and the 
whole seem blended in inextricable confusion. By observation of 
their relations when hypertro})hied during pregnancy Helie* has shown 
that they may, speaking roughly, bo divided into three layers — an ex- 
ternal ; a middle, chiefiy longitudinal ; and an internal, chiefiy circular. 
Into the details of their distribution, as described by him, it is needless 
to enter at length. BrieHy, however, he describes the external laver as 
arising posteriorly at the junction of the body and cervix, and spreading 
upward and over the fundus. From this are derived the nuiscular 
fibres found in the broad and round ligaments, and more particularlv 
described by Rouget. The middle layer is made up of strong fasciculi, 

^ Gompamiive Hn^toloff;/, vol. iii. ; Stid. Sac. 2)-ans., p. 477. 
^ The Ut('ru,'< and /As- Appciuhk/cs, p. (V,V2. 

^ "On the Stnictiiro of the Mucous Membrane of tlie I'terus," ObsteL Jonrn., 
1 875-7 (), vol. iii. p. 4JM». 

* Rfchcrchc.^ .^ur Id l)if<posit{o)i (/I's Fibres nuu<eulairt\< d-: i' llcriis. Paris, 1S(>9. 



62 ORGAXS COXCERXED IX PARTURITIOX. 

which run upward, but decussate and unite witli each other in a 
remarkable manner, so that those which are at first superficial become 
most deeply seated, and vice versa. The muscular fasciculi which form 
this coat curve in a circular manner round the large veins, so as to form 
a species of muscular canal, through which they run. This arrange- 
ment is of peculiar importance, as it affords a satisfactory explanation 
of the mechanism by which hemorrhage after delivery is prevented. 
The internal layer is mainly composed of circular rings of muscular 
fibres, beginning round the openings of the Fallopian tubes, and form- 
ing wider and wider circles which eventually touch and iutcrlace with 
each other. They surround the internal os, to whicli they form a kind 
of sphincter. In addition to these circular fibres on the internal uterine 
surface, both anteriorly and posteriorly, there is a well-marked triangu- 
lar layer of longitudinal fibres, the base being above and the apex below, 
which sends muscular fasciculi into the mucous membrane. 

The anatomy of the lining membrane of the uterus has been the sub- 
ject of considerable discussion. Its existence has been denied by many 
authorities, most recently by Snow Beck,^ who maintains that it is in no 
sense a mucous membrane, but only a softened portion of true uterine 
tissue. It is, however, pretty generally admitted by the best authorities 
that it is essentially a mucous membrane, differing from others only in 
being more closely adherent to the subjacent structures, in consequence 
of not possessing any definite connective-tissue framework. 

It is a pale pink membrane of considerable thickiiess, most marked 
at the centre of the body, ^^•here it forms from one-eighth to one- fourth 
of the thickness of the whole uterine walls. At the internal os uteri 
it terminates by a distinct border, which separates it from the mucous 
membrane lining the cervical cavity. 

On the surface of the mucous membrane may be observed a multi- 
tude of little openings about one-thirtieth of a line in width (Fig. 24). 

Fig. 24. 





Lining Membrane of Uterus, showing netw ;.rk of capiliaries and oritices ot uterine glands. 

(After Farre.i 
From tlie boilv. From orifice of Fallopian tube. 

These are the orifices of the utricular glands, which are found in im- 
mense numbers all over the cavity of the uterus, and very closely 
agglomerated together. They are little cul-de-sacs, narrower at their 
mouths than in their length, the blind extremities of which are found 
in the subjacent tissues (Fig. 26). AVilliams describes them as running 
obliquely toward the surface at the lower third of the cavit}^, perpen- 
dicularly at its middle, while toward the fundus they are at first per- 

1 065^ Trans., 1872, vol. xiii. p. 294. 



THE FEMALE GENERATIVE ORGANS. 



63 



pendicular, and then oblique in their coarse (Fig. 25j. By others they 
are described as being often twisted and corkscrew-like. One or more 
may unite to form a common orifice, several 
of which may open together in little pits or Fig. 25. 

depressions on the surface of the mucous mem- 
brane. These glands are composed of struc- 
tureless membrane lined with epithelium, the 
precise character of which is doubtful. By 
some it is described as columnar, by others 
tessellated, and by some, again, as ciliated. 
The most generally received opinion is that it 
is columnar, but not ciliated; therein differing 
from the epithelium covering the surface of 
the membrane, which is undoubtedly ciliated, 
the movements of the cilia being from within 
outward. Williams, however, has observed 
cilia in active movement on the columnar epi- 
thelium lining the glands, and also states that 
at the deep-seated extremities of the glands, 
which penetrate between the muscular fibres 
for some distance, the columnar epithelium is 
replaced by rounded cells. The capillaries of 
the mucous membrane run down between the 
tubes, forming a lacework on their surfaces 
and round their orifices. No true papillae 
exist in the membrane lining the uterine 
cavity. The mucous membrane of the uterus 
is peculiar in being always in a state of change 

and alteration, being thrown off at each men- The course of the* Glands in the 
strual period in the form of debris in conse- Ke'^o^fhT'i^e^^us-Sz^^^^^^^^ 
quence of fatty degeneration of its structures, 
and re-formed afresh by proliferation of the 
cells of the muscular and connective tissues, probably from below upward, 
the new membrane commencing at the internal os. Hence its ap})ear- 
ance and structure vary considerably according to the time at which it 
is examined. The subject, however, will be more particularly studied 
in connection with menstruation. 

The mucous membrane of the cervix is much thicker and more trans- 
parent than that of the body of the uterus, from which it also differs in 
certain structural peculiarities. The general arrangements of its folds 
and surface have already been described. The lo^ver half of the mem- 
brane lining the cavity of tlie cervix, and the whole of that covering 
its external or vaginal portion, are closely set \\\\\\ a large number of 
minute filiform or clavate papilh^ (Fig. 27). Their structure is similar 
to that of the mucous membrane itself, of which they seem to be merely 
elevations. They each contain a vascular loop (Fig. 28\ and they are 
believed by KiHan and h^irre to be mainly concerned in giving sensi- 
bility to this part of the 'generative tract. All over the interior of tlie 
cervix, both on tlie ridges of the nuicous membrane and between their 
folds, are a verv laro^e number o( nuu\>us toUicles consist in;:,- o( a 




before the onset of a menstrual 
period. (After Williams.) 



64 



ORGANS CONCERNED IN PARTURITION. 



structureless membrane lined with cylindrical epithelium and inti- 
mately united with connective tissue. They cease at the external 
orifice of the cervix, and they secrete the thick, tenacious, and alka- 
line mucus which is generally found filling the cervical cavity. 
The transparent follicles, known as the " ovula Nabothii/' which are 
sometimes found in considerable numbers in the cavity of the cervix, 
consist of mucous follicles the mouths of which have become obstructed 
and their canals distended by mucous secretion. The low^er third of the 
cervical canal, as well as the exterior of the cervix, is covered with 
pavement epitlielium ; while on its upper portion is found a colum- 
nar and ciliated epithelium similar to that lining the uterine cavity. 

Fig. 26. 




Vertical Section through the Mucous Membrane of the Human Uterus. (After Turner.) 
e. Columnar epithelium; the cilia are not represented, g g. Utricular glands, ct ct. Interglandular con- 
nective tissue. V V. Blood-vessels, m m. Muscularis mucosae (*f-). 

Bandl ^ describes the cervical mucous membrane as extending much 
higher in the virgin than in women Avho have borne children, being 
traceable in the former nearly to the middle of the body of the uterus. 
During the first pregnancy he believes that the upper portion of the 
cervix is taken up into the body of the uterus, its mucous membrane 
never regaining the arrangement peculiar to that of the cervical 
canal. 

The arteries of the uterus are derived from the internal iliac and 
from the ovarian. They enter the uterus between the folds of the 
broad ligaments, and, penetrating its muscular coat, anastomose freely 
with each other and with the corresponding vessels of the opposite 

^Arch.f. Gyndk., 1879, Bd. xiv. S. 237. 



THE FEMALE GENERATIVE ORGANS. 

Fig. 27. 



65 









Villi of Os Uteri stripped of Epithelium. (After Tyler Smith and Hassall.) 

side. They are described by Williams ^ as entering the uterus on its 
sides, and then running a somewhat superficial course, being separated 
from the peritoneum by a thin layer of muscular fibres. They are 

Fig. 28. 




Villi of Uterus, covorod with pavomont opitholiinn nud coutaiuins;- Un^^od vessels:. (, Viler Tyler 

Smith imd Hassall. ■! 

1 Traiki. Ohst. ^oct\-lu, 1885. vol. xxvii. p. 112. 



66 OBGANS CONCERNED IN PARTURITION. 

here placed in a distinct layer of connective tissue, and give off 
branches which j^ass perpendicularly toward the uterine canal. Their 
walls are thick and well developed, and they are remarkable for their 
very tortuous course, forming spiral curves, especially in the upper part 
of the uterus. They end in minute capillaries which form the fine 
meshes surroundirfg the glands, and in the cervix give off the loops 
entering the papilla. Beneath the uterine mucous membrane these 
capillaries form a plexus terminating in veins without valves, which 
unite with each other to form the large veins traversing the substance 
of the uterus, known during pregnancy as the uterine sinuses, the walls 
of Avhich are closely adherent to the uterine tissues. These veins run 
a similar course to the arteries, and end in a venous plexus lying in the 
layer of connective tissue already mentioned, which Williams believes 
to be the true submucous tissue of the uterus, the thick layer of mus- 
cular tissue between it and the uterine cavity being really '^ muscularis 
mucosse.'^ In consequence of this arrangement the circulation of the 
uterus can hardly be disturbed by mechanical causes. The veins, freely 
anastomosing with each other, pass from the uterus to the folds of the 
broad ligaments, where they unite to form, with the ovarian and vagi- 
nal veins, a large and well-developed venous network known as the 
^pampiniform plexus. 

The lymphatics of the uterus are large and well developed, and they 
have recently, and with much probability, been supposed to play an 
important part in the production of certain puerperal diseases. A 
more minute knowledge than we at present possess of their course and 
distribution will probably throw much light on their influence in this 
respect. According to the researches of Leopold,^ who has studied 
their minute anatomy carefully, they originate in lymph-spaces between 
the fine bundles of connective tissue forming the basis of the mucous 
lining of the uterus. Here they are in intimate contact with the utric- 
ular glands and the ultimate ramifications of the uterine blood-vessels. 
As they pass into the muscular tissue they become gradually narrowed 
into lymph-vessels and spaces, which have a very complicated arrange- 
ment, and which eventually unite together in the external muscular 
layer, especially on the sides of the uterus, to form large canals which 
probably have valves. Immediately under this peritoneal covering 
these lymph- vessels form a large and characteristic network covering 
the anterior and posterior surfaces of the uterus, and present, in various 
parts of their course, large ampullae. They then spread over the Fal- 
lopian tubes. The lymphatics of the body of the uterus unite with 
the lumbar glands, those of the cervix with the pelvic glands. 

The distribution and arrangement of the nerves of the uterus have 
been the subject of much controversy. They are derived mainly from 
the ovarian and hypogastric plexuses, inosculating freely with each 
other between the folds of the broad ligament, from which they enter 
the muscular tissue of the uterus, generally, but not invariably, follow- 
ing the course of the arteries. They are chiefly derived from the 
sympathetic ; but as the hypogastric plexus is connected with the sacral 
nerves, it is probable that some fibres from the cerebro-spinal system are 
'Arch. J. Gyndk., 1873, Bd. vi. Heft 1, S. ]. 



THE FEMALE GENERATIVE ORGANS. 67 

distributed to the cervix. It is now generally admitted that nervous 
filaments are distributed to the cervix even as far as the external os, 
although their existence in this situation has been denied by Jobert and 
other writers. The ultimate distribution of the nerves is not yet made 
out. Polle describes a nerve-filament as entering the papilla? of the 
cervical mucous membrane along with the capillary loop, and Franken- 
hauser says the nerve-fibres surround the muscles of the uterus in the 
form of plexuses and terminate in the nuclei of the muscle-cells. 

Anomalies of the Uterus. — Various abnormal conditions of the 
uterus and vagina are occasionally met with which it is necessary to 
mention, as they may have an important practical bearing on parturi- 
tion. The most frequent of these is the existence of a double, or par- 
tially double, uterus (Fig. 29), similar to that found normally in many 

Fig. 29. 




Bifid Uterus. (After Farre.) 

of the lower animals. This abnormality is explained by the develop- 
ment of the organ during foetal life. The uterus is formed out of 
structures existing only in early foetal life, known as the Wolffian 
bodies. These consist of a number of tubes situated on either side of 
the vertebral column and opening externally into an excretory duct. 
Along their external border a hollow canal is formed, termed the canal 
of Miiller, which, like the excretory ducts, proceeds to the common 
cloaca of the digestive and urinary organs which then exists. The 
canal of Miiller unites with its fellow of the opj^-jsite side to form the 
uterus and Fallopian tubes in t\\Q female, and subsequently the central 
partition at their point of junction disa])]ienrs. If, however, the prog- 
ress of development be in any way clieeked, the central ]>artition may 
remain. Then we have produced either a complete double uterus or 
the uterus bicornis, which is bifid at its upper extremity only : or a 
double vagina, each leading to a separate uterus. 

If pregnancy occur in any of thi^se anomalous uteri — and many 
.such cases are recorded — serious troubles may folhnv. It may ha]>pen 
that one horn of the double uterus is not sufficiently large \o admit t>f 
pregnancy going on to term, and nq^ture may (H'l'ur, Tt is supj^osed 
that some cases, presumed to W tubal g(^statii>n, wcm-c roallv thus expli- 
cable. Tnquvgnation may also i>ccur in the t\\t> cornna at ditVeivnt 



68 



OEGAyS CONCERNED IN PARTURITION. 



times, leading to superfcetation. It is, however, quite possible that 
impregnation may occur in one horn of a bifid uterus, and labor be 
completed without anything unusual being observed. A remarkable 
case of this sort has been recorded by Dr. Ross of Brighton,' in which 
a patient miscarried of twins on July 16, 1870, and on October 31, 
fifteen weeks later, she Avas delivered of a healthy child. Careful 
examination showed the existence of a complete double uterus, each 
side of which had been impregnated. Curiously enough, this patient 
had formerly given birth to six living children at term, nothing 
remarkable having been observed in her labors. It can only rarely 
happen that, under such circumstances, so favorable a result will 
follow, and more or less difficulty and danger may generally be 
expected. Occasionally the vagina only is double, the uterus being 
single. Dr. Matthews Duncan has recorded some cases of this kind,^ 
in which the vaginal septum formed an obstacle to the birth of the 
child, and required division. 

Fig. so. 




Uterus Septus Uniforis. (From Kussmaul, after Gravel.) 

a. Vagina. 6. Single os uteri, c. Partition of uterus, thick above and thin below, d d. Eight and left 

uterine cavities, e e. Two ridges in the posterior wall of the cervix. 

[Double uteri are of several distinct types, the extremes of which are 
the "partitioned uterus," where the organ is single without and double 
within, and the " completely bifid uterus/' where there is a double va- 
gina and cervix with a Y-shaped or double-barrelled body. The for- 
mer can only be diagnosticated from within, and is rarely discovered 
until after the second stage of a labor has been completed. In a case 
reported by Dr. B. F. Baer of Philadelphia the patient bore twins, one 
foetus from each compartment, the birth of which was followed by two 

^Lancet, 1871, vol. ii. p. 188. ^Researches in Obstetrics, p. 443. 



THE FEMALE GENERATIVE ORGANS. 69 

single placentse at intervals of a quarter of an hoar. Where tliere is 
only one foetus the uterus develops mainly on one side, and the unoccu- 
pied one lies much lower than the fundus of the other. Dr. Drysdale of 
this city discovered one such case by the touch after labor, and no doubt 
a careful scrutiny would find that they are less rare than might be 
presumed. 

Pregnancy in a uterus unicornus is apt to terminate fatally by rup- 
ture, but exceptional cases may occur and the foetus be delivered at term. 
In one case seen by the writer the development of the abnormal uterus 
gave rise to much pain and distress for several months, and an extra- 
uterine pregnancy was regarded as almost certain by the family physi- 
cian. The child was a female of four pounds, and died in three days 
from an undeveloped duodenum and an imperforate rectum : the cornu 
was on the right side. — Ed.] 

Lig-aments of the Uterus. — The various folds of peritoneum which 
invest the uterus serve to maintain it in position, and they are described 
as its ligaments. They are the broad, the vesico-uterine, and sacro- 
uterine ligaments ; the round ligaments are not peritoneal folds like the 
others. 

The broad ligaments extend from either side of the uterus, where 
their laminse are separated from each other, transversely across to the 
pelvic wall, and thus divide the cavity of the pelvis into two parts, the 
anterior containing the bladder, the posterior the rectum. Their upper 
borders are divided into three subsidiary folds, the anterior of which 
contains the round ligament, the middle the Fallopian tube, and the 
posterior the ovary. The arrangement has received the name of the 
ala vespertilionisj from its fancied resemblance to a bat's wing. Between 
the folds of the broad ligaments are found the uterine vessels and nerves, 
and a certain amount of loose cellular tissue continuous with tlie pelvic 

Fig. 31. 




Adult Parovarium, Ovary, aud Vallopin i \aor Kobolt.'* 

fascire. PTere is situated 'that peculiar struc^turt^ called the (M^nn of 
Kosenmiiller, or the p(Vor(n'i)n)} {V\'j:. '^1\ whii'h is the remains ot' the 
AVolffian IkmIv nnd corri^sponds (o iho opiilidyniis in the ni;iK\ This 



70 



ORGAXS COyCEBXED IX PAETUEITIOX. 



may best be seen in yonng snbjects bv holding np the broad ligaments 
and looking through them by transmitted light ; but it exists at all 
ages. It consists of several tubes (eight or ten according to Farre, 
eighteen or twenty according to Bankes ^), ^vhich are tortuous in their 
course. They are arranged in a pyramidal form, the base of the pyra- 
mid being toward the Fallopian tube, its apex being lost on the surface ' 
of the ovarv. Thevare formed of fibrous tissue and lined with pave- 
ment epithelium. They have no excretory duct or communication with 
either the uterus or ovary, and their function, if they have any, is 
unknown. 

A number of muscular fibres are also found in this situation, Iving 
between the meshes of the connective tissue. They have been particu- 
larly studied by Rouget, who describes them as interlacing with each 
other, and forming an open network continuous with the muscular tis- 
sues of the uterus^Fig. 32j. They are divisible into two layers, the 






^f 



^i- 



Fig. 32. 




# 



A 






^ 





Posterior View of Muscular and Vascular Arrangements. (After Rouget.) 
Vessels- 12 3. Vaginal, cervical, and uterine plexuses. -1. Arteries of body of uterus. 5. Arteries supply- 
in"' ovarv. Mvxevlar Fasciculi : 6, 7. Fibres attached to vagina, symphysis pubis, and sacro-iliac joint. 
8. ^Muscniar fasciculi from uterus and broad ligaments. 9, 10, 11, 12. Fasciculi attached to ovary and 
Fallopian tubes. 



anterior of Avhich is continuous with the muscular fibres of the anterior 

surface of the uterus, and goes to form part of the round ligament ; the 

posterior arises from the "posterior wall of the uterus, and proceeds 

^Bankes, On the Woljjian Bodies. 



THE FEMALE GENERATIVE ORGANS. 71 

transversely outward, to become attached to the sacro-iliac synchondrosis. 
A continuous muscular envelope is thus formed which surrounds the 
whole of the uterus, Fallopian tubes, and ovaries. Its function is not 
yet thoroughly established. It is supposed to have the effect of retract- 
ing the stretched folds of peritoneum after delivery, and more especially 
of bringing the entire generative organs into harmonious action during 
menstruation and the sexual orgasm ; in this way explaining, as we 
shall subsequently see, the mechanism by which the fimbriated extrem- 
ity of the Fallopian tube grasps the ovary prior to the rupture of a 
Graafian follicle. 

The round lig-aments are essentially muscular in structure. They 
extend from the upper border of the uterus, with the fibres of which 
their muscular fibres are continuous, transversely, and then obliquely 
downward, until they reach the inguinal rings, where they blend with 
the cellular tissue. In the first part of their course the muscular fibres 
are solely of the unstriped variety, but soon they receive striped fibres 
from the transversalis muscles and the columns of the inguinal ring, 
which surround and cover the unstriped muscular tissue. In addition 
to these structures they contain elastic and connective tissue and arterial, 
venous, and nervous branches ; the former from the iliac or cremasteric 
arteries, the latter from the genito-crural nerve. According to Mr, 
Rainey, the principal function of these ligaments is to draw the uterus 
toward the symphysis pubis during sexual intercourse, and thus to favor 
the ascent of the semen. 

The vesico -uterine ligaments are two folds of peritoneum passing 
in front from the lower part of the body of the uterus to the fundus of 
the bladder. 

The utero-sacral lig-aments consist of folds of peritoneum of a 
crescentic form, with their concavities looking inward ; they start from 
the lower part of the posterior surface of the uterus, and curve backward 
to be attached to the third and fourth sacral vertebrae. Within their 
folds exist bundles of muscular fibres continuous with those of the 
uterus, as well as connective tissue, vessels, and nerves. The experi- 
ments of Savage, as well as of other anatomists, show that these 
ligaments have an important influence in preventing downward dis- 
placement of the womb. 

Daring pregnancy all these ligaments become greatly stretched and 
unfolded, rising out of the pelvic cavity and accommodating themselves 
to the increased size of tlie gravid uterus ; and they again contract to 
their natural size, possibly through the agency of the muscular fibres 
contained within them, after delivery has taken place. 

The Fallopian tubes, the homologuos of the vasa deferentia in the 
male, are structures of great })hysiological interest. Thev serve the 
double purpose of conveying the semen to the ovarv and of carrvino" the 
ovule to the uterus. From the latter function they mav be looked on 
as the excretory ducts of the ovaries ; but, unlike other excretory ducts, 
they are movable, so that they may a[>[)ly themselves to the part of the 
ovaries from which tiie ovule is to come; and s(^ great is their mobilitv 
thtit there is reason to believe tluit a I^allopian tube mav even o-rasp the 
ovary of the opposite side. Each tube proceeds trom the upper angle 



72 



ORGANS CONCERNED IN PARTURITION. 



of the uterus at first transversely outward, and then doAvnward, back- 
ward, and inward, so as to reach the neighborhood of the ovary. In tiie 
first part of its course it is straight ; afterward it becomes flexuous and 
twisted on itself. It is contained in the upper part of the broad 
ligament, where it may be felt as a hard cord. It commences at the 
uterus by a narrow opening, admitting only the passage of a bristle, 
known as ostium uterinum. As it passes through the muscular walls of 
the uterus the tube takes a somewhat curved course, and opens into the 
uterine cavity by a dilated aperture. From its uterine attachment the 
tube expands gradually until it terminates in its trumpet-shaped ex- 
tremity; just before its distal end, however, it again contracts slightly. 
The ovarian end of the tube is surrounded by a number of remarkable 
fringe-like processes. These consist of longitudinal membranous fim- 
briae, surrounding the aperture of the tube like the tentacles of a polyp, 
varying considerably in number and size and liaving their edges cut 
and subdivided. On their inner surface are found both transverse and 
longitudinal folds of mucous membrane continuous with those lining 
the tube itself (Fig. 33). One of these fimbriae is always larger and 



Fig. 83. 




Fallopian Tube laid open. (After Eichard.) 

a, h. Uterine portion of tube, c, d. Plicje of mucous membrane, e. Tubo-ovarian ligaments and fringes. 

/. Ovary, g. Round ligaments. 

more developed than the rest, and is indirectly united to the surface of 
the ovaiy by a fold of peritoneum proceeding from its external surface. 
Its under surface is grooved so as to form a channel, open below. The 
function of this fringe-like structure is to grasp the ovary during the 
menstrual nisus ; and the fimbria which is attached to the ovary would 
seem to guide the tentacles to the ovary which they are intended to 
seize. One or more supplementary series of fimbriae sometimes exist, 
which have an aperture of communication with the canal of the Fallo- 
pian tube, beyond its ovarian extremity. His has recently shown that 
the fimbriated extremity of the tube, after running over the upper part 
of the ovary, turns down along its free border, so that its aperture lies 



THE FEMALE GENERATIVE ORGANS. 73 

below it, ready to receive the ovule when expelled from the Graafian 
follicle.! 

The tubes themselves consist of peritoneal, muscular, and mucous 
coats. The peritoneum surrounds the tube for three-fourths of its cal- 
ibre, and comes into contact with the mucous lining at its fimbriated 
extremity, the only instance in the body where such junction occurs. 
The muscular coat is principally composed of circular fibres, with a 
few longitudinal fibres interspersed. Its nmscular character has been 
doubted, but Farre had no difficulty in demonstrating the existence of 
muscular fibres both in the human female and many of the lower ani- 
mals. According to Robin, the muscular tissue of the Fallopian tubes 
is entirely distinct from that of the uterus, from which he describes it 
as being separated by a distinct cellular septum. The mucous lining is 
thrown into a number of remarkable longitudinal folds, each of which 
contains a dense and vascular fibrous septum with small muscular 
fibres, and is covered with columnar and ciliated epithelium. The 
apposition of these produces a series of minute capillary tubes, along 
which the ovules are propelled, the action of the cilia, which is toward 
the uterus, apparently favoring their progress. 

The ovaries are the bodies in which the ovules are formed and 
from which they are expelled, and the changes going on in them, in 
connection with the process of ovulation, during the whole period 
between the establishment of puberty and the cessation of menstru- 
ation, have an enormous influence on the female economy. Normally, 
the ovaries are two in' number ; in some exceptional cases a supplemen- 
tary ovary has been discovered, or they may be entirely absent. They 
are placed in the posterior folds of the broad ligaments, usually below 
the brim of the pelvis, behind the Fallopian tubes, the left in front of 
the rectum, the right in front of some coils of the small intestine. 
Their situation varies, however, very much under different circum- 
stances, so that they can scarcely be said to have a fixed and normal 
position ; most probably, however, as has been recently shown by His,^ 
they are normally placed close below the brim of the pelvis, with their 
long diameters almost vertical, and immediately above the aperture of 
the distal extremity of the Fallopian tubes. In pregnancy they rise 
into the abdominal cavity with the enlarging uterus ; and in certain 
conditions thev are dislocated downward into Douglas' space, where 
they may be felt through the vagina as rounded and very tender bodies. 

The folds of the broad ligament, between which the ovaries are 
placed, form for them a kind of loose mesentery. Each of them is 
united to the up})oi' angle of the uterus by a special ligament called the 
utero-ovarian. This is a rounded band of organic muscular fibres 
about an inch in length, continuous with the su])erlicial nmscular fibres 
of the posterior wall of the uterus, and attached to the inner extremity 
of the ovary. It is surrounded by jieritoneum, and through it the 
muscular fibres, which form an important integral part in the structure 
of the ovaries, are conveyed to them. The ovary is also attached to 
the fimbriated extremity of the Fallopian tube in the manner already 
described. 

^ His, Airliirfiir Anat. und Phps., 18S1. » Op. cit. 



74 



OEGANS CONCERNED IN PARTURITION. 



The ovaiy is of aD irregular oval shape (Fig. 34), the upper border 
being convex, the lower — through which the vessels and nerves enter — 
being straight. The anterior surface, like that of the uterus, is less 
convex than the posterior. The outer extremity is more rounded and 



Fig. 34. 




A A. Ovary enlarged under Menstrual Nlsus. 
B. Eipe follicle projecting on its surface, a, a, a. Traces of previously ruptured follicles. 

bulbous than the inner, which is somewhat pointed and eventually lost 
in its proper ligament. By these peculiarities it is possible to distin- 
guish the left from the right ovary after they have been removed from 
the body. The ovary varies much in size under different circum- 
stances. On an average, in adult life it measures from one to tw^o 
inches in length, three-quarters of an inch in wddth, and about half an 
inch in thickness. It increases greatly in size during each menstrual 
period — a fact which has been demonstrated in certain cases of ovarian 
hernia, in which the protruded ovary has been seen to swell as men- 
struation commenced ; also during pregnancy, when it is said to be 
double its usual size. After the change of life it atrophies, and 
becomes rough and wrinkled on its surface. Before puberty the sur- 
face of the ovary is smooth and polished, and of a whitish color. After 
menstruation commences its surface becomes scarred by the rupture of 
the Graafian follicles (Fig. 34, a a), each of which leaves a little linear 
or striated cicatrix of a brownish color ; and the older the patient the 
greater are the number of these cicatrices. 

The structure of the ovary has been made the subject of many 
important observations. It has an external covering of epithelium, 
originally continuous w^ith the peritoneum, called by some the germ- 
epithelium, in consequence of the ovules being formed from it in early 
foetal life. In the adult it is separated from the peritoneum at the 
base of the organ by a circular white line, and it consists of columnar 
epithelium, differing only from the epithelium lining the Fallopian 
tubes, watli which it is sometimes continuous through the attached fim- 
bria uniting the tube and the ovary, in being destitute of cilia. Imme- 
diately beneath this covering is the dense coat known as the tunica 




THE FEMALE GENERATIVE ORGANS. 75 

albuginea, on account of its whitish color. It consists of short con- 
nective-tissue fibres arranged in laminae, among whicli are interspersed 
fusiform muscular fibres. At the point where the vessels and nerves 
enter the ovary this membrane is raised into a ridge, which is contin- 
uous with the utero-ovarian ligament and is called the /dlnm. The 
tunica albuginea is so ultimately blended with the stroma of the ovary 
as to be inseparable on dissection ; it does not, however, exist as a distinct 
lamina, but is merely the external part of the proper structure of the 
ovary, in which more dense connective tissue is developed than elsewhere. 
On making a longitudinal section of the ovary (Fig. 35) it will be 
seen to be composed of two parts, the more internal of which is of a 
reddish color from the number of vessels that 
ramify in it, and is called the medullary or Fig. 

vascular zone; while the external, of a 
whitish tint, receives the name of the cortical 
or parenchymatous substance. The former 
consists of loose connective tissue interspersed 
with elastic and a considerable number of 
muscular fibres. According to E-ouget ^ and 
His,^ the muscular structure forms the greater 
part of the ovarian stroma. The latter de- 
scribes it as consisting essentially of inter- 
woven muscular fibres, which he terms the 
^^ fusiform tissues,^' and which he believes to ^°^^^^fary'' SS^y^L^"^^ 
be continuous with the muscular layers of 

the ovarian vessels. The former believes that the muscular fasciculi 
accompany the vessels in the form of sheaths, as in erectile tissues. Both 
attribute to the muscular tissues an important influence in the expulsion 
of the ovules and in the rupture of the Graafian follicles. \Valdeyer 
and other writers, however, do not consider it to be so extensively 
developed as Rouget and His believe. The cortical substance is the 
more important, as that in which the Graafian follicles and ovules are 
formed. It consists of interlaced fibres of connective tissue containing 
a large number of nuclei. The muscular fibres of the medullary sub- 
stance do not seem to penetrate into it in the human female. In it are 
found the Graafian follicles, Avliich exist in enormous numbers from the 
earliest periods of life and in all stages of development (Fig. 3G). 

The Graafian Follicles. — According to the researches of Pfliiger, 
Waldeyer, and other German writers, the Graafian follicles are formed in 
early foetal life by cylindrical inflections of the epithelial covering of the 
ovary, whicli dip into the substance of the gland. These tubular 
filaments anastomose with each other, and in tluMu an> fornuHl the 
ovules, whicli are originally the epithelial cells lining the tubes. Por- 
tions become shut off" from the rest of the tilaments and form the Graaf- 
ian follicles. The ovules, on this vie\v, are highly-developixl epithelial 
cells, originally derived from tlu^ surface of the ovary, ;ind not developed 
in its stroma. These tubular Hhunents disa}^pear shortly after birth, 
but they have recently been detected by 81avyansky ^^ in the ovaries of a 

' Journal dc Pli)i.<ioL, i, p. 787. ' Schnitzels Airh.j. Mikroscop. AmxL, lSo-3. 

^ Anuah's dc Gijncc, Feb., 1S71. 



76 



OEGASS COXCEBXED IX PARTURITIOX. 



woman thirty years of age. These obseryations haye been modified by 
Dr. Foulis.^ ' He recognizes the origin of 'the oyules from thegerm-epi- 

FiG. 3G. 




Section through the Cortical Part of the Ovary. 
e Surface epithelium, s .?. Ovarian stroma. 11. Lar-e-sized Graafian follicles. 2 2. Middle-sized; and 
3 3. Small-sized Graafian follicles, o. Ovule within Graafian follicle, r r. Blood-vessels in tne 
stroma. ^. Cells of the membrana granulosa. (After Turner.) 

thelium coyering the surface of the oyary, which is itself deriyed from the 
Wolffian body. He belieyes all the oyules to be formed from the germ- 

FiG. 37. 




Vertical Section through the Ovary of the Human Foetus. 

ss. Ovarian stroma containing c c c. Fusiform 



a n. Germ- epithelium, with o o. Developing ovules in it 

r(>nnprtivp-ti««ue cornuscles. v v. Capillarv T)lood-vessels. v, , 

connectne tu.ue ^'^^ P"^cn _^^.^^^^ ^^^^i ^^ ^.^^ ^^^^ ^^^^^^^ ^.^^ ^ primordial ovule, with the connective- 



lu the centre of the figure an involution 



of the srerm-epithelium it tt ,• x 

tissue coi-puscles arranging themselves round it. (Alter 1 ouUs.) 

epithelium corpuscles which become imbedded in the stroma of the oyary 
by the outgrowth of processes of vascular connective tissue, fresh germ- 
1 Proceedings of the Royal Soc. of Edinh., April, 1875, and Journ. of Aiiat and Fhys., 
vol. xiii., 1879. 



THE FEMALE GENERATIVE ORGANS. 



77 



epithelial corpuscles being coDstantly produced on the surface of the 
organ up to the age of two and a half years^ to take the place of those 
already imbedded in its stroma. He believes the Graafian follicles to 
be formed by the growth of delicate processes of connective tissue 
between and around the ovules, but not from tubular inflections of the 
epithelium covering the gland, as described by Waldeyer (Fig. 37j. 
This view is supported by the researches of Balfour,^ who arrives at the 
conclusion that the whole egg-containing part of the ovary is really the 
thickened germinal epithelium, broken up into a kind of mesh work by 
growths of vascular stroma. According to this theory, Pflliger's tubular 
filaments are merely trabeculse of germinal epithelium, modified cells of 
which become developed into ovules. 

The greater proportion of the Graafian follicles are only visible with 
the high powers of the microscope, but those which are approaching 
maturity are distinctly to be seen by the naked eye. The quantity of 
these follicles is immense. Foulis estimates that at birth each human 
ovary contains not less than thirty thousand. JSTo fresh follicles appear 
to be formed after birth, and as development goes on some only grow, 
and by pressure on the others destroy them. Of those that grow, of 
course only a few ever reach maturity ; they are scattered through the 
substance of the ovary, some developing in the stroma, others on the 
surface of the organ, where they eventually burst, and are discharged 
into the Fallopian tube. 

A ripe Graafian follicle has an external investing membrane (Fig. 38), 

Fig. 38. 




Diagrammatic Section of Graafian Follicle. 

1. Ovum. 2. Monibrana granulosa. 3. External nionibiano of Graafian follicle. 4. Its vessels, 
rian stroma. 6. Cavity of Graafian follicle. T. External covering of ovary. 



5. Ova- 



which is generally described as consisting of two distinct lavors : the 
external, or tunica fibro,<ia, highly vascular and formed of coniuvtive 
tissue; the internal, or fu)iica jyropria, composed of young connective 
tissue, containing a hirge number of fiisitorm or stellate cells, and tonn- 
ing a basement membrane to the epithelial layer which lies internal to it. 
These layers, however, apj>ear to be essentially formed o\' condensed 
ovarian stroma. Within this capsule is the epithelial lining, calKnl the 

^ F. M. Balfour, "Structure and Dovolopuient of Vertebrate Ovary." Quarterly 

Journal of 3[icroscopical Sciour, \o\. xviii., 1878, 



78 OBGAXS COyCERXED IX PAETURITIOX. 

memhrana granulosa, consisting of columnar epithelial cells, "s^'hich, 
according to Fonlis, are originally formed from the nuclei of the fibro- 
nuclear tissue of the stroma of the ovarv, but wliich, according to AVal- 
deyer and Balfour, are formed from the germinal epithelium itself. At 
one part of the circumference of the ovisac is situated the ovule, aroimd 
which the epithelial cells are congregated in greater quantity, constituting 
the projection known as the discus proligerus. The remainder of tlie 
cavity of the follicle is filled with a small quantity of transparent fluid, 
the liquor foUiculi , tvnyersed by three or four minute bands, the retinac- 
ula of Barry, which are attached to the opposite walls of the follicular 
cavity, and apparently serve the purpose of suspending the ovule and 
maintaining it in a proper position. In many young follicles this 
cavity does not at first exist, the follicle being entirely filled by the 
ovule. According to Waldeyer, the liquor folliculi is formed by the 
disintegration of the epithelial cells, the fluid thus produced collecting 
and distending the interior of the follicle. 

The ovule is attached to some part of the internal surface of the 
Graafian follicle. It is a rounded vesicle about y^th of an inch in 
diameter, and is surrounded by a layer of columnar cells, distinct from 
those of the discus ]3i'oligerus, in which it lies. It is invested by a 
transparent elastic membrane, the zona pellucida, or vitelline membrane. 
In most of the lower animals the zona pellucida is perforated by nume- 
rous very minute pores, only visible under the higliest powers of the 
microscope ; in others there is a distinct aperture of a larger size, the 
micropyle, allowing the passage of the spermatozoa into the interior of 
the ovule. It is possible that similar apertures may exist in the human 
ovule, but they have not been demonstrated. Within the zona pellucida 
some embryologists describe a second fine membrane, the existence of 
which has been denied by Bischoff. The cavity of the ovule is filled 
with a viscid yellow fluid, the ijelk, containing numerous granules. It 
entirely fills the cavity, to the walls of which it is non-adherent. In 
the centre of the yelk in young, and at some portion of its periph- 
ery in mature ovules, is situated the germinal vesicle, which is a 
clear circular vesicle, refracting light strongly, and about -^th of a line 
in diameter. It contains a few granules, and a nucleolus, or germinal 
spot, which is sometimes double. 

From within outward, therefore, we find — 

1. The ^^/T/u'/ia/ spot ; round this 

2. The germinal vesicle, contained in 

3. The yell', which is surrounded by the 

4. Zona pellucida, with its layers of columnar epithelial cells. 
These constitute the ovule. 

The ovule is contained in 

The Graafian follicle, and lies in that part of its epithelial lining 
called the 

Discus proligerus, the rest of the follicle being occupied by the liquor 
folliculi. Round these we have the epithelial lining or memhrana gran- 
ulosa, and the external coat, consisting of the tunica proprria and the 
tunica fibrosa. 

The vascular supply of the ovary is complex. The arteries enter at 



THE FEMALE GENERATIVE ORGANS. 



79 



the hilum, penetrating the stroma in a spiral curve, and are ultimately 
distributed in a rich capillary plexus to the follicles. The large veins 
unite freely with each other, and form a vascular and erectile plexus 
continuous with that surrounding the uterus, called the bulb of the 



Fig. 39. 




Bulb of Ovary. 

V. Uterus, o. Ovary and utero-ovarian ligament, r. Fallopian tube. 1. Utero-ovarian vein. 2. Pampin- 
iform ovarian plexus. 3. Commencement of spermatic vein. 

ovary (Fig. 39). Lymphatics and nerves exist, but their mode of 
termination is unknown. 

The Mammary Glands. — To complete the consideration of the 
generative organs of the female we must study the mammary glands, 
which secrete the fluid destined to nourish the child. In the human 
subject they are two in number, and instead of being placed upon the 
abdomen, as in most animals, they are situated on either side of the 
sternum, over the pectorales majora muscles, and extend from the third 
to the sixth ribs. This position of the glands is obviously intended to 
suit the erect position of the female in suckling. They are convex 
anteriorly, and flattened posteriorly where they rest on the muscles. 
They vary greatly in size in different subjects, chiefly in proportion to 
the amount of adipose tissue they contain. In man and in girls 
previous to puberty they are rudimentary in structure; while in preg- 
nant women they increase greatly in size, the true glandular structures 
becoming much hypertrophied. Anomalies in shape and jiosition are 
sometimes observed. Su])plementaiy mammte, one or more in number, 
situated on the upper portion of the mammse, are sometimes met with, 
identical in structure with the normally situated glands ; or, more com- 
monly, an extra nipple is observed by the side of the normal one. In 
some races, especially the African, the mannna^ are so large and pendu- 
lous that the mother is able to suckle her child over her shoulder. 

The skin covering the gland is soft and supple, and during preg- 
nancy often becomes covered with fine white lines, while large blue 
veins may be observed coursing over. Underneath it is a quantity o^ 
connective tissue, containing a considerable amount of fat, which ex- 
tends beneath the true glandular structure. This is composed of t'rom 
fifteen to twenty lobes, each of which is formed of a number of lobules. 
The lobules are produced' by the aggregation of the terminal acini in 
wdiicli the milk is formed. The acini are minute cul-de-siics opening 
into little ducts, which unite with eacli other until tliev form a larov 



80 OBGAyS COXCEEXED IX PARTURITIOX. 

duct for each lobule ; the ducts of each lobule unite with each other, 
until they end in a still larger duct common to each of the fifteen 
or twenty lobes into which the gland is divided, and eventually open 
on the surface of the nipple. These terminal canals are known as the 
galactophorous ducts (Fig. 40). They become widely dilated as they 

Fig. 40. 




/ :^^^^^^'^.'^..y^ 



-^^'. 



y^m. 



r~^H^^ 



1. Galactophorous ducts. 2. Lobnli of the mammary gland. 

approach the nipple, so as to form reservoirs in which milk is stored 
until it is required, but when they actually enter the nipple they 
again contract. Sometimes they give ofP lateral branches, but, accord- 
ing to Sappey, they do not anastomose with each other, as some anato- 
mists have described. These exci-etory ducts are composed of con- 
nective tissue, with numerous elastic fibres on their external surface. 
Sappey and Robin describe a layer of muscular fibres, chiefly developed 
near their terminal extremities. They are lined with columnar epithe- 
lium, continuous with that in the acini ; and it is by the distension of 
its cells with fatty matter, and their subsequent bursting, that the 
milk is formed. 

The nipple is the conical projection at the summit of the mamma, 
and it varies in size in different women. Not unfrequently from the 
continuous pressure to which it has been subjected by the dress, it is so 
depressed below the surface of the skin as to prevent lactation. It is 
generally larger in married than in single women, and increases in size 
during pregnancy. Its surface is covered with numerous papillae, giv- 
ing it a rugous aspect, and at their bases the orifices of the lactif- 
erous ducts open. Here are also the openings of numerous sebaceous 
follicles, w^hich secrete an unctuous material supposed to protect and 
soften the integument during lactation. Beneath the skin are mus- 
cular fibres, mixed with connective and elastic tissues, vessels, nerves, 
and lymphatics. When the ni]~)ple is irritated it contracts and hardens, 
and by some this is attributed to its erectile properties. The vascular- 
ity, however, is not great, and it contains no true erectile tissue ; the 
hardening is, therefore, due to muscular contraction. Surrounding the 
nipple is the areola, of a pink color in virgins, becoming dark from the 
development of pigment-cells during pregnancy, and always remaining 
somewhat dark after childbearing. On its surface are a number of 
prominent tubercles, sixteen to twenty in number, which also become 
largely developed during gestation. They are supposed by some to 



OVULATION AND MENSTRUATION. 81 

secrete milk and to open into the lactiferous tubes : most probably they 
are composed of sebaceous glands only. Beneath the areola is a circular 
band of muscular fibres, the object of which is to compress the lactifer- 
ous tubes which run through it, and thus to favor the expulsion of their 
contents. The mammae receive their blood from the internal mammary 
and intercostal arteries^ and they are richly supplied with lymphatic 
vessels, which open into the axillary glands. The nerves are derived 
from the intercostal and thoracic branches of the brachial plexus. 

The secretion of milk in women who are nursing is accompanied 
by a peculiar sensation, as if milk were rushing into the breast, called 
the "draught,'^ which is excited by the efforts of the child to suck and 
by various other causes. The sympathetic relations between the mammse 
and the uterus are very well marked, as is shown in the unimpreg- 
nated state by the fact of the frequent occurrence of sympathetic 
pains in the breast in connection with various uterine diseases, and 
after delivery by the well-known fact that suction produces reflex con- 
traction of the uterus, and even severe after-pains. 



CHAPTER III. 

OVULATION AND MENSTKUATION. 

Functions of the Ovary. — The main function of the ovary is to 
supply the female generative element, and to expel it, when ready 
for impregnation, into the Fallopian tube, along which it passes into 
the uterus. This process takes place spontaneously in all viviparous 
animals, and without the assistance of the male. In the lower animals 
this periodical discharge receives the name of the oestrum or rut, at 
which time only the female is capable of impregnation and admits the 
approach of the male. In the human female the periodical discharge 
of the ovule, in all probability, takes place in connection with menstru- 
ation, which may therefore be considered to be the analogue of the rut 
in animals. Between each menstrual period Graafian follicles undergo 
changes which prepare them for rupture and the discharge of their 
contained ovules. After rupture certain changes occur which have for 
their object the healing of the rent in the ovarian tissue through which 
the ovule has escaped, and the filling up of the cavity in which it was 
contained. This results in the formation of a peculiar body in the sub- 
stance of the ovary, called the corpus lufcion, which is essentially modi- 
fied should pregnancy occur, and is of great interest and iniportancw 
During the whole of the childbearing epoch the periodical matura- 
tion and rupture of the Graafian follicles are going on. If imprcirna- 
tion does not take place, the ovules are discharged and lost; if it does, 
ovulation is stopped, as a general rule, during gestation and lactation. 

Theory of Menstruation. — This, broadly speaking, is an outline ot^ 
the modern theory of menstruation, which was lirst broacheil in the vciir 



82 OEGANS CONCERNED IN PARTURITION. 

1821 by Dr. Power^ and subsequently elaborated by Xegrier, Bischoif, 
Raciborski, and many other writers. Although the sequence of events 
here indicated may be taken to be the rule, it must be remembered that 
it is one subject to many exceptions, for undoubtedly ovulation may 
occur without its outward manifestation, menstruation, as in cases in 
which impregnation takes place during lactation or before menstruation 
has been established, of which many examj^les are recorded. These ex- 
ceptions have led some modern writers to deny the ovular theory of 
menstruation, and their views will require subsequent consideration. 

In order to understand the subject properly, it will be necessary to 
study the sequence of events in detail. 

Chang-es in the Graafian Follicle. — The changes in the Graafian 
follicle which are associated with the discharge of the ovules com- 
prise — 1. Maturation. As the period of puberty approaches a certain 
number of the Graafian follicles, fifteen to twenty in number, increase 
in size and come near the surface of the ovary. Amongst these one 
becomes especially developed preparatory to rupture, and upon it for 
the time being all the vital energy of the ovary seems to be con- 
centrated. A similar change in one, sometimes in more than one, 
follicle takes place periodically during the whole of the childbearing 
epoch in connection with each menstrual period, and an examination 
of the ovary will show several follicles in difPerent stages of develop- 
ment. The maturing follicle becomes gradually larger, until it forms a 
projection on the surface of the ovaiy from five to seven lines in 
breadth, but sometimes even as large as a nut (Fig. 34). This growth 
is due to the distension of the follicle by the increase of its contained 
fluid, which causes it so to press upon the ovarian structures covering 
it that they become thinned, separated from each other, and partially 
absorbed, until they eventually readily lacerate. The follicle also 
becomes greatly congested; the capillaries coursing over it become 
increased in size and loaded with blood, and, being seen through the 
attenuated ovarian tissue, give it, when mature, a bright-red color. 
At this time some of these distended capillaries in its inner coat lace- 
rate, and a certain quantity of blood escapes into its cavity. This 
escape of blood takes place before rupture, and seems to have for its 
principal object the increase of the tension of the follicle, of which it 
has been termed the menstruation. Pouchet was of opinion that the 
blood collects behind the ovule and carries it up to the surface of the 
follicle. By these means the follicle is more and more distended, until 
at last it ruptures (Plate II., Fig. 1), either spontaneously or, it may be, 
under the stimulus of sexual excitement. Whether the laceration takes 
place during, before, or after the menstrual discharge is not yet posi- 
tively known : from the results of post-morten examination in a num- 
ber of women who died shortly before or after the period, AVilliams 
believes that the ovules are expelled before the monthly floAv com- 
mences.^ In order that the ovule may escape, the laceration must, 
of course, involve not only the coats of the Graafian follicles, but also 
the superincumbent structures. 

Laceration seems to be aided by the growth of the internal layer of 

* Proceedings of the Royal Society, 1875. 



FLale III. 







Fig I. 

^reca-vilPy ruptured and hloody Sra^piam 
fo?Pici& , jus'r de-v^fopinrf' ivil-o a Corpus tul-tuv 



Fii. 2. 

Corpus Cul'euvn ireta Jays aftex •meyislruAtion. 




Fig. .i. 

vv^'ict^i ftt^s vie-oe> ruptured, 




Corpus Pufc.ii>n» or i)Veon?»»iaj| 



(M.USTHATION.S OF THK CORPUS lA'TKr M. ( AF TKK HAITONM 

9^.'i)tU-.-<:»S.f(lft.?f.,i. 



OVULATION AND MENSTRUATION 



the follicle, which increases in thickness before rupture, and assumes a 
characteristic yellow color from the number of oil-globules it tlien con- 
tains. It is also greatly facilitated, if it be not actually produced, by 
the turgescence of the ovary at each menstrual period, and by the con- 
traction of the muscular fibres in the ovarian stroma. As soon as the 
rent in the follicular walls is produced, the ovule is discharged, sur- 
rounded by some of the cells of the membrana granulosa, and is re- 
ceived into the fiml^riated extremity of the Fallopian tube, whicli grasps 
the ovary over the site of the rupture. By the vibratile cilia of its epi- 
thelial lining it is then conducted into the canal of the tube, along 
which it is propelled, partly by ciliary action and partly by muscular 
contraction in the walls of the tube. 

After the ovule has escaped certain characteristic changes occur in 
the empty Graafian follicle, which have for their object its cicatrization 
and obliteration. There are great differences in the changes which 
occur when impregnation has followed the escape of the ovule, and they 
are then so remarkable that they have been considered certain signs of 
pregnancy. They are, however, differences of degree rather than of 
kind. It will be well, however, to discuss them separately. 

As soon as the ovule is discharged the edges of the rent through 
which it has escaped become agglutinated by exudation, and the follicle 
shrinks, as is generally believed, by the inherent elasticity of its internal 
coat, but, according to Robin, who denies the existence of this coat, from 
compression by the musular fibres of the ovarian stroma. In proportion 
to the contraction that takes place the inner layer of the follicle, the 
cells of which have become greatly hypertrophied and loaded with fat- 
granules previous to rupture, is thrown into numerous folds (Plate II., 
Fig. 2). The greater the amount of contraction the deeper these folds 
become, giving to a section of the follicle an appearance similar to that 
of the convolutions of the brain (Fig. 41). These folds in the human 
subject are generally of a bright-yellow 
color, but in some of the mammalia they 
are of a deep red. The tint was formerly 
ascribed by Raciborski to absorption of the 
coloring matter of the blood-clot contained 
in the follicular cavity — a theory he has 
more recently abandoned in favor of the 
view maintained by Coste, that it is due to 
the inherent color of the cells of the lin- 
ing membrane of the follicle, which, 
though not well marked in a single cell, 
becomes very apparent en viassc. The ex- 
istence of a contained blood-clot is also 
denied by the latter })hysiologist, except 
as an unusual ]mthological condition ; and 
he describes the cavity as containing a 
gelatinous and plastic fluid which be- 
comes absorbed as contraction advances, 
of Dalton,^ however, show the existence ot 

* "Report t>n the C\)rpiit; Lutomn." Anurican Gii)uv( 



Fig 




Soot ion o! I 
Imoum thrv 



Mv. snowinc oorinis. 
wooks a tier luoustru- 



aiion. (^Aftor nalton.) 

.lie more recent researelies 
a central blood-clot in the 



Tr 



is: 



,-ol. 



p. Ill, 



84 OEGASS COXCERXED IN PARTURITION. 

cavity of the follicle; and he considers its occasional absence to be con- 
nected with disturbance or cessation of the menstrual function. The 
folds into which the membrane has been thrown continue to increase in 
size^ from the proliferation of their cells, until they unite and become 
adherent, and eventually fill the follicular cavity. By the time that 
another Graafian follicle is matured and ready for rupture the diminu- 
tion has advanced considerably, and the empty ovisac is reduced to a 
very small size. The cavity is now nearly obliterated, the yellow 
color of the convolutions is altered into a whitish tint, and on section 
the corpus luteum has the appearance of a compact white stellate 
cicatrix, which generally disappears in less than forty days from the 
period of rupture. The tissue of the ovary at the site of laceration 
also shrinks, and this, aided by the contraction of the follicle, gives rise 
to one of those permanent pits or depressions which mark the surface of 
the adult ovary. Slavyansky^ has shown that only a few of the im- 
mense number of Graafian follicles undergo these alterations. The 
greater proportion of them seem never to discharge their ovules, but, 
after increasing in size, undergo retrogressive changes exactly similar in 
their nature, but to a much less extent, to those which result in the 
formation of a corpus luteum. The sites of these may afterward be 
seen as minute striae in the substance of the ovary. 

Should pregnancy occur, all the changes above described take place ; 
but, inasmuch as the ovary partakes of the stimulus to which all the 
generative organs are then subjected, they are much more marked and 
apparent (Plate II., Fig. 4). Instead of contracting and disappearing 
in a few weeks, the corpus luteum continues to grow until the third or 
fourth month of pregnancy ; the folds of the inner layer of the ovisac 
become large and fleshy and permeated by numerous capillaries, and 
ultimately become so firmly united that the margins of the convolutions 
thin and disappear, leaving only a firm fleshy yellow mass, averaging 
from 1 to 1 J inches in thickness, which surrounds a central cavity, often 
containing a whitish fibrillated structure, believed to be the remains of 
a central blood-clot. This was erroneously supposed by Montgomery to 
be the inner layer of the follicle itself, and he conceived the yellow sub- 
stance to be a new formation between it and the external layer ; while 
Robert Lee thought it was placed external to both the external and 
internal layers. 

Between the third and fourth months of pregnancy, when the corpus 
luteum has attained its maximum of development (Fig. 42), it forms a 
firm projection on the surface of the ovary, averaging about one inch in 
length and rather more than half an inch in Jbreadth. After this it 
commences to atrophy (Fig. 43), the fat-cells become absorbed, and the 
capillaries disappear. Cicatrization is not complete until from one to 
two months after delivery. 

On account of the marked appearance of the corpus luteum it was 
formerly considered to be an infallible sign of pregnancy ; and it was 
distinguished from the corpus luteum of the non-pregnant state by being 
called a " true ^' as opposed to a " false " corpus luteum. From what 
has been said, it will be obvious that this designation is essentially 

^ Archil', de Phys., March, 1874. 



OVULATION AND MENSTRUATION. 



80 



wrong, as the difference is one of degree only. iJalton ' aj)plies the 
term " false corpus luteum '^ to a degenerated condition sometimes met 
with in an unruptured Graafian follicle, consisting in reabsorption of* 
its contents and thickening of its walls (Plate II., Fig. 3j. It differs 



Fig. 42. 





Corpus Luteum of the Fuuith Muuth of 
Pregnancy. (After Dalton.) 



Corpus Luteum of Pregnancy at 
Term. (After Dalton.) 



from the " true " corpus luteum in being deeply seated in the substance 
of the ovary, in having no central clot, and in being unconnected with 
a cicatrix on the surface of the ovary. Nor do obstetricians attach by 
any means the same importance as they did formerly to the presence of 
the corpus luteum as indicating impregnation ; for, even when well 
marked, other and more reliable signs of recent delivery, such as 
enlargement of the uterus, are sure to be present, especially a^ the time 
when the corpus luteum has reached its maximum of development ; 
while after delivery at term it has no longer a sufficiently characteristic 
appearance to be depended on. 

Menstruation. — By the term mcnstrnation (catamenia, periods, etc.) 
is meant the periodical discharge of blood from the uterus which occurs, 
in tlie healthy woman, every lunar month, except during pregnancv and 
lactation, wlien it is, as a rule, susj^ended. 

The first appearance of menstruation coincides with the establishment 
of puberty, and the physical changes that accompany it indicate that tlie 
female is capable of conce])tion and childbearing, although exceptional 
cases are recorded in which pregnancy occurred before menstruation had 
begun. In temperate climates it gi^nerally conunences between the 
fourteenth and sixteenth years, the largest number of cases being met 
with in the fifteenth year. This rule is subjec^t to many excejnions, it 
being by no means very rare for menstruati(Mi to become established as 
early as the tenth or eleventh year or to be delayed until the eighteenth 
or twentieth. Beyond these physiological limits a tew cases are tVom 
time to time met with in which it has begun in early intancv or not 
until a comparatively late period of lite. 

Influence of Climate, Race, etc. — Various accidental circunisiances 

^ Op. cit., p. 04. 



86 OBGAXS COXCERXED IX PARTVRITIOX. 

have much to do with its establishment. As a rule, it occurs somewhat 
earlier iu tropical, aud later in very cold than in temperate, climates. 
The influence of climate has been unduly exaggerated. It used to be 
generally stated that in the Arctic regions women did not menstruate 
until they were of mature age, and that in the tropics girls of ten or 
t^\•elve years of age did so habitually. The researches of Robertson of 
^Manchester ^ first showed that tlie generally received opinions were erro- 
neous, and the collection of a large number of statistics has corroborated 
his opinion. There can be no doubt, however, that a larger proportion 
of girls menstruate early in warm climates. Joulin found that in 
tropical climates, out of 1635 cases the largest proportion began to 
menstruate between the twelfth and thirteenth years, so that there is an 
average difference of more than two years betweeen the period of its 
establishment in the tropics and in temperate countries. Harris ^ states 
that among the Hindoos 1 to 2 per cent, menstruate as early as nine years 
of age ; 3 to 4 per cent, at ten ; 8 per cent, at eleven ; and 25 per cent, 
at twelve ; while in London or Paris probably not more than 1 girl in 
1000 or 1200 does so at nine years. The converse holds true with 
regard to cold climates, although we are not in possession of a sufficient 
number of accurate statistics to draw very reliable conclusions on this 
point ; but out of 4715 cases, including returns from Denmark, Norway 
and Sweden, Russia, and Labrador, it was found that menstruation was 
established on an average a year later than in more temperate countries. 
It is probable that the mere influence of temperature has much to do in 
producing these differences, but there are other factors the action of 
which must not be overlooked. Raciborski attributes considerable im- 
portance to the effect of race ; and he has quoted Dr. AVebb of Calcutta 
to the effect that English girls in India, although subjected to the same 
climatic influence as the Indian races, do not, as a rule, menstruate earl- 
ier than in England ; while in Austria girls of the Magyar race men- 
struate considerably later than those of German parentage.^ The sur- 
roundings of girls and their manner of education and living have 
probably also a marked influence in promoting or retarding its establish- 
ment. Thus, it vf\\\ commence earlier in the children of the rich, who 
are likely to have a highly-developed nervous organization, and are 
habituated to luxurious living and a premature stimulation of the mental 
faculties by novel-reading, society, and the like; while amongst the 
hard-worked poor or in girls brought up in the country it is more likely 
to begin later. Premature sexual excitement is said also to favor its 
early appearance, and the influence of this among the factory-girls of 
Manchester, who are exposed iu the course of their work to the tempta- 
tions arising from the promiscuous mixing of the sexes, has been pointed 
out by Dr.'Clay.^ 

[Precocious Physical "Womanhood. — AVe emphasize the term 
" physical," because in a mental and moral sense the subjects are for- 
tunately, with rare exceptions, only children in years and tastes. Pre- 

* Edin. Med. and Surg. Journ., 1832. 

'-* Amer. Journ. of Obdet, 1870-71, vol. iii. p. 611: R. P. Harris, "On Early 
Pubertv." 

3 Op. cit, p. 227. * Brit. Record of Obstei. Med., vol. i. 



OVULATION AND MENSTRUATION. 87 

cociously developed girls are, as a rule, of very unusual size for their 
years, and usually enjoy good health, while precocity in male children is 
apt to be associated with semi-idiocy and epilepsy. Where menstruation 
begins in the first year, the girl may at three or four years of age pre- 
sent the evidences of puberty in the appearance of pubic and axillary 
hair, rounded mammae, and a broad pelvis, associated with well-rounded 
arms and legs and a strength and height much beyond her years. In 
three children born in this State, these characteristics were marked 
respectively, at four and a half years, five, and six. The five-year-old 
girl was a beautifully formed miniature woman, and the one of six was 
large, fat, and had the developed features of twice her age ; still, she was 
only a child in tastes, and as such devoted to her dolls and toys. The 
sexual passion is very rarely a marked characteristic in such subjects, 
as it is in the other sex, and hence the ability to procreate has rarely 
been tested; but occasionally in the lower classes pregnancy has 
occurred at an early age. 

The youngest English mother on record was nine years seven months 
and nine days old when Mr. Henry Dodd of Billington, York, who 
was present at her birth, delivered her of a sev^en-pound healthy child, 
after a labor of six hours, on March 17, 1881. She commenced to 
menstruate at twelve months, and became pregnant about six weeks 
before she was nine years old.^ 

The youngest American mother became such at ten years and thirteen 
days, giving birth to a child of seven and three-quarter pounds. She 
also menstruated at one year, and at the time of her labor was 4 ft. 7 
inches in height and weighed 100 pounds. The case was reported by 
Dr. Rowlett of Kentucky.^ A still younger mother was reported by 
Schmith more than a century ago. The child began to menstruate at 
two years, and when eight years and ten months old bore a dead foetus 
which was thought by its development to have reached its full term. 
The mother had the mammae and pubes of a girl of seventeen.^ Ed.] 

Changes Occurring" at Puberty. — The first appearance of men- 
struation is accompanied by certain well-marked changes in the female 
system, on the occurrence of which we say that the girl has arrived at 
the period of puberty. The pubes become covered with hair, the breasts 
enlarge, the pelvis assumes its fully-developed form, and the general 
contour of the body fills out. The mental qualities also alter : the girl 
becomes more shy and retiring, and her whole bearing indicates the 
change that has taken place. The menstrual discharge is not estab- 
lished regularly at once. For one or two months there may be only 
premonitory symptoms — a vague sense of discomfort, pains in the 
breasts, and a feeling of weight and heat in the back and loins. There 
then may be a discharge of mucus tinged with blood, or pure blcuul, 
and this may not again show itself for several monthb\ Such irregu- 
larities are of little consequence on the first establishment of the tunc- 
tion, and need give rise to no apprehension. 

Duration. — As a rule, the discharge recurs every twenty-eight davs, 
t 

[' Barnes' Obstetric }fcd{nnc amf Suiycri/.] 

I'-' 'rrnn.<i/h'(tnia }ft(L Journ.. vol. vii, p. 447.] 

[^ Sue's AV,s'((iV hit<(ori<itn\<, Paris. 1779. vol. ii. p. 814.] 



88 ORGANS CONCERNED IN PARTURITION. 

and with some women with such regularity that they can foretell its 
appearance almost to the hour. The rule is, however, subject to very 
great variations. It is by no means uncommon, and strictly within the 
limits of health, for it to appear every twentieth day, or even with less 
interval ; while in other cases as much as six weeks may habitually 
intervene between two periods. The period of recurrence may also 
vary in the same subject. I am acquainted with patients who some- 
times only have twenty-eight days, at others as many as forty-eight 
days, between their periods, without their health in any way suffering. 
Joulin mentions the case of a lady who only menstruated two or three 
times in the year, and whose sister had the same peculiarity. 

The duration of the period varies in different women and in the 
same ^voman at chfferent times. In this country its average is four or 
five days, while in France, Dubois and Brierre de Boismont fix eight 
days as the most usual length. Some women are only unwell for a few 
hours, while in others the period may last many days beyond the aver- 
age without being considered abnormal. 

The quantity of blood lost varies in different women. Hippocrates 
puts it at oxviij, which, however, is much too high an estimate. Arthur 
Farre thinks that from 5ij to 5iij is the full amount of a healthy 
period, and that the quantity cannot habitually exceed this without pro- 
ducing serious constitutional effects. Rich diet, luxurious living, and 
anything that unhealthily stimulates the body and mind will have an 
injurious effect in increasing the flow ; which is therefore less in hard- 
worked countrywomen than in the better classes and residents in towns. 

It is more abundant in warm climates, and our countrywomen in 
India habitually menstruate over-profusely, becoming less abundantly 
unwell when they return to England. The same observation has been 
made with regard to American women residing in the Gulf States, w4io 
improve materially by removing to the Lake States. Some women 
appear to menstruate more in summer than in winter. I am acquainted 
w^ith a lady who spends the Avinter in St. Petersburg, where her periods 
last eight or ten days, and the summer in England, where they never 
exceed four or five. The difference is probably due to the effect of the 
over-heated rooms in which she lives in Russia. 

The daily loss is not the same during the continuance of the period. 
It generally is at first slight, and gradually increases so as to be most 
profuse on the second or third day, and as gradually diminishes. Toward 
the last days it sometimes disappears for a few hours, and then comes on 
again, and is apt to recur under any excitement or emotion. 

As the menstrual fluid escapes from the uterus it consists of pure 
blood, and if collected through the speculum it coagulates. The ordi- 
nary menstrual fluid does not coagulate unless it is excessive in amount. 
Various explanations of this fact have been given. It was formerly 
supposed either to contain no fibrin or an unusually small amount. 
Retzius attributes its non-coagulation to the presence of free lactic and 
phosphoric acids. The true explanation was first given by Mandl, who 
proved that even small quantities of pus or mucus in blood were suf- 
ficient to keep the fibrin in solution ; and mucus is always present to 
greater or less amount in the secretions of the cervix and vagina, which 



OVULATION AND MENSTRUATION 89 

mix with the menstrual blood in its passage through the genital tract. 
If the amount of blood be excessive, however, the mucus present is 
insufficient in quantity to produce this effect, and coagula are then 
formed. 

On microscopic examination the menstrual fluid exhibits blood-cor- 
puscles, mucus-corpuscles, and a considerable amount of epithelial 
scales, the last being the debris of the epithelium lining the uterine 
cavity. According to Virchow, the form of the epithelium often proves 
that it comes from the interior of the utricular glands. The color of 
the blood is at first dark, and as the period progresses it generally 
becomes lighter in tint. In women who are in bad health it is often 
very pale. These differences doubtless depend upon the amount of 
mucus mingled with it. The menstrual blood has always a character- 
istic faint and heavy odor, whicli is analogous to that which is so dis- 
tinct in the lower animals during the rut. Raciborski mentions a lady 
who was so sensitive to this odor that she could always tell to a certainty 
when any woman was menstruating. It is attributed either to decom- 
posing mucus mixed with the blood, which, when partially absorbed, 
may cause the peculiar odor of the breath often perceptible in menstru- 
ating women, or to the mixture with the fluid of the sebaceous secretion 
from the glands of the vulva. It probably gave rise to the old and 
prevalent prejudices as to the deleterious properties of menstrual blood, 
which, it is needless to say, are altogether without foundation. 

It is now universally admitted that the source of the menstrual blood 
is the mucous membrane lining the interior of the uterus, for the blood 
may be seen oozing through the os uteri by means of the speculum and 
in cases of procidentia uteri ; while in cases of inverted uterus it may be 
actually observed escaping from the exposed mucous membrane and col- 
lecting in minute drops upon its surface. During the menstrual uisus 
the whole mucous lining becomes congested to such an extent that, in 
examining the bodies of women who have died during menstruation, it 
is found to be thicker, larger, and thrown into folds, so as to completelv 
fill the uterine cavity. The capillary circulation at this time becomes 
very marked, and the mucous meml^rane assumes a deep-red hue, the 
network of capillaries surrounding the orifices of the utricular glands 
being especially distinct. Tliese facts liave an unquestionable connec- 
tion with tlie production of the discharge, but there is nuich difloronce 
of opinion as to the precise mode in which the blood escapes from the 
vessels. Coste believed that the blood transudes through the coats of the 
capillaries without any laceration of their structure. Farre inclines to 
the hypothesis that i\\Q uterine ca])illaries terminate by open mouths, the 
escape of blood through these between the menstrual jun-iods beinu' ]->re- 
vented by nuiscular contraction of the uterine walls. Pouehet believed 
that during each menstrual epoch the entire nnicous membrane is broken 
down and cast off in the form of miiuite shreds, a fresh nnicous mem- 
brane being developed in the interval between two perioils. Ourlng 
this process the capillary network would be laid btire and ruptured, and 
the escape of blood readily accounted for. Tyler Smith, who adoptixi 
this theory, states that he has iVe(|uently seen the uterine nnicous mem- 
brane in wiMuen who have died diu-ino- menstruation in a slate of disso- 



90 ORGANS CONCERNED IN PARTURITION. 

liition, with the broken loops of the capillaries exposed. The phe- 
nomena attending the so-called membranous dysmenorrhoea, in which 
the mucous membrane is thrown off in shreds or as a cast of the uterine 
cavity — the nature of which was first pointed out by Simpson and 
Oldham — have been supposed to corroborate this theory. This view is, 
in the main, corroborated by the recent researches of Engelmann/ 
Williams/ and others. Williams describes the mucous lining of the 
uterus as undergoing a fatty degeneration before each period, which 
commences near the inner os, and extends over the whole mucous mem- 
brane and down to the muscular wall. This seems to bring on a certain 
amount of muscular contraction, which drives the blood into the capil- 
laries of the mucosa, and these, having become degenerated, readily 
rupture and permit the escape of the blood. The mucous membrane 
now rapidly disintegrates, and is cast ofP in shreds with the menstrual 
discharge, in which masses of epithelial cells may always be detected. 
Engelmann, however, holds that the fatty degeneration is limited to the 
superficial layers, and that a portion only of the epithelial investment is 
thrown off. As soon as the period is over, the formation of a new 
mucous membrane is begun, which arises either from proliferation of 
the elements of the muscular coat itself, or from the proliferation of 
the epithelial cells lining the bases of the uterine glands which remain 
imbedded in the muscular tissue after the mucous membrane has been 
thrown off, and at the end of a week the whole uterine cavity is lined 
by a thin mucous membrane. This grows until the advent of another 
period, when the same degenerative changes occur unless impregnation 
has taken place, in which case it becomes further developed into the 
decidua. Loewenthal ^ believes that the menstral decidua is produced 
by the imbedding of an ovum in the lining membrane of the uterus, 
which, if impregnation occurs, is developed into the decidua of preg- 
nancy. If conception does not take place, the ovum dies, and this is 
followed by the degeneration and expulsion of the menstrual decidua, 
accompanied by a flow of blood, which is the menstrual discharge. 

Theory of Menstruation. — That there is an intimate connection 
between ovulation and menstruation is admitted by most physiologists, 
and it is held by many that the determining cause of the discharge is 
the periodic maturation of the Graafian follicles. There is abundant 
evidence of this connection, for we know that when, at the change of 
life, the Graafian follicles cease to develop, menstruation is arrested; 
and when the ovaries are removed by operation, of which there are now 
numerous cases on record, or when they are congenitally absent, men- 
struation does not generally take ])lace. A few cases, however, have 
been observed in which menstruation continued after double ovari- 
otomy, or the removal of the ovaries by Battey's operation, and these 
have been used as an argument by those physiologists who doubt the 
ovular theory of menstruation. Slavyansky has particularly insisted on 

^ American Journal of Obstetrics, 1875-76, vol. viii. p, 30. 

^ "On the Stnictnre of the Mucous Membrane of the Uterus/' Obsfet. Journ.j 
1875-76, vol. iii. p. 496. 

^ Arch.f. Gyji., Bd. xxiv. Hft. 2, S. 169: '^ Eine neuQ Deutung des Menstruations- 
Prozess." 



OVULATION AND MENSTRUATION. 91 

such cases, which, however, are probably susceptible of explanation. 
It may be that the habit of menstruation may continue for a time even 
after the removal of the ovaries ; and it has not been shown that men- 
struation has continued permanently after double ovariotomy, although 
it certainly has occasionally, although quite exceptionally, done so 
for a time. It is possible, also, that in such cases a small portion of 
ovarian tissue may have been left unremoved, sufficient to carry on 
ovulation. Koberts, a traveller quoted by Depaul and Gueniot in their 
article on menstruation in the Dictionnairedes Sciences medicaleSjrelsites 
that in certain parts of Central Asia it is the custom to remove both 
ovaries in young girls who act as guards to the harems. These women, 
known as "hedjeras," subsequently assume much of the virile type and 
never menstruate. The same close connection between ovulation and 
the rut of animals is observed, and supports the conclusion that the rut 
and menstruation are analogous. The chief difference between ovulation 
in man and the lower animals is that in the latter the process is not 
generally accompanied by a sanguineous flow. To this there are excep- 
tions, for in monkeys there is certainly a discharge analogous to men- 
struation occurring at intervals. Another point of distinction is that in 
animals connection never takes place except during the rat, and that it 
is then only that the female is capable of conception ; Avhile in the 
human race conception only occurs in the intervals between the periods. 
This is another argument brought against the ovular theory, because, it 
is said, if menstruation depend on the rupture of a Graafian follicle and 
the emission of an ovule, then impregnation should only take place 
during or immediately after menstruation. Coste explains this by sup- 
posing that it is the maturation and not the rupture of the follicle which 
determines the occurrence of menstruation, and that the follicle may 
remain unruptured for a considerable time after it is mature, the escape 
of the ovule being subsequently determined by some accidental cause, 
such as sexual excitement. However this may be, there is good reason 
to believe that the susceptibility to conception is greater during the 
menstrual epochs. Raciborski believes that in the large proportion of 
cases impregnation occurs in the first half of the menstrual interx-iil or 
in the few days immediately preceding the appearance of the discharge. 
There are, however, very numerous exceptions, for in Jewesses, Avho 
almost invariably live apart from their husbands for eight days after 
the cessation of menstruation, impregnation nuist constantly occur at 
some other period of the interval, and it is certain that they are not less 
prolific than other people. This rule with them is very strictly adhered 
to, as Avill be seen by the accompanying interesting letter from a medical 
friend who is a well-known member of that comnumity, and which I 
have permission to publish.^ This fact is of itself sutUcient to disprove 

1 li> Uk.i!\aui> Stkv.kt, lUssKi I. Sqvakk, .Julv -1. 1ST:".. 

My Dear Sir : 

1. Tothebest of my knowlodceaiid boliof, tho law whit'li pvi>hibits soxiial intoivinn->e 
anions? Jews tor isoven clear days at'ter tbe eessation ot' nienstruaiion is almost nnivor- 
sally observed ; the exceptions Miot being sntlieient to vitiate statistics. The law has 
perlia|)s fewer exceptions im the Continent— es{HH'ially Knssia and Toland. where the 
Jewish popnlation is very ureat — than in Knghnul. Kven here. lu>wever, women who 
observe no other cerenionial law observe this, and olinu' to it after evervthinc else is 



92 ORGANS COyCERNED IN PARTURITION. 

the theory advanced by Dr. Avrard/ that irapreguation is impossible in 
the latter half of the menstrual interval. This and the other reasons 
referred to undoubtedly throw some doubt on the ovular theory, but they 
do not seem to be sufficient to justify the conclusion that menstruation is 
a physiological process altogether independent of the development and 
maturation of the Graafian follicles. All that they can be fairly held 
to prove is that the escape of the ovules may occur independently of 
menstruation, but the weight of evidence remains strongly in favor 
of the theory which is generally received. It should be stated that 
Lawson Tait attributes considerable influence in menstruation to the 
Fallopian tubes themselves ; but his views on this point, based on obser- 
vations made after the removal of the ovaries for certain morbid con- 
ditions, cannot yet be taken as proved ; and Thornton ^ has related a 
case in which he removed both tubes, leaving the ovaries intact, in 
which menstruation subsequently went on as before. 

The cause of the monthly periodicity is quite unknown, and will 
probably always remain so. Goodman^ has suggested what he calls the 
'^cyclical theory of menstruation," which refers the phenomena to a gen- 
eral condition of the vascular system specially localizing itself in the 
generative organs, and connected with rhythmical changes in their nerve- 
centres. It cloes not seem to me, however, that he has satisfactorily 
proved the recurrence of the conditions which his ingenious theory 
assumes. The purpose of the loss of so much blood is also somewhat 
obscure. To a certain extent it must be considered an accident or com- 
plication of ovulation produced by the vascular turgescence. I^or is it 
essential to fecundation, because women often conceive during lactation, 
when menstruation is suspended, or before the function has become 
established. It may, however, serve the negative purpose of relieving 
the congested uterine capillaries, which are periodically filled wath a 
supply of blood for the great growth which takes place when concep- 

tlirown overboard. There are doubtless many exceptions, especially among the better 
classes in England, who keep only three days after the cessation of the menses. 

2. The law is — as you state — that should the discharge last only an hour or so, or 
should there be only one gush or one spot on the linen, the fiye days during which the 
period might continue are observed ; to which must be superadded the seven clear days 
— twelve days per mensem in which connection is disallowed. Should any discharge 
be seen in the intermenstrual period, seven days would have to be kept, but not the 
five, for such irregular discharge. 

3. The "bath of purification," which must contain at least eighty gallons, is used on 
the last night of the seven clear days. It is not used till after a bath for cleansing 
purposes ; and from the night when such " purifying " bath is used Jewish women are 
accustomed to calculate the commencement of pregnancy. That you should not have 
heard it is not strange : its mention would be considered highly indelicate. 

4. Jewish women reckon their pregnancy to last nine calendar or ten lunar months 
— 270 to 280 days. There are no special data on which to reckon an average, nor do 
I know of any books on the subject, except some Talmudic authorities, which I will 
look up for you if you desire it. Pray make no apologies for writing to me : any infor- 
mation I possess is at your service. 

I am, dear sir, yours very truly, 
Dr. Playfair. * A. Asher. 

P.S. — Tlae biblical foundation for the law of the seven clear days is Leviticus xv. 
verse 19 till the end of the chapter — especially verse 28. 

1 Rev. de Therap. Med.-Chir., 1867. 

2 Ohstet. Trans., 1886, vol. xxviii. p. 41. 

^ American Journal of Obstetrics, 1878, vol. xi. p. 673. 



OVULATION AND MENSTRUATION 93 

tion has occurred. Thus immediately before each period the uterus 
may be considered to be placed by the afflux of blood in a state of 
preparation for the function it may be suddenly called upon to per- 
form. That the discharge relieves a state of vascular tension which 
accompanies ovulation is proved by the singular phenomenon of vicari- 
ous menstruation which is occasionally, though rarely, met with. It 
occurs in cases in which, from some unexplained cause, the discharge 
does not escape from the uterine mucous membrane. Under such cir- 
cumstances a more or less regular escape of blood may take place from 
other sites. The most common situations are the mucous membranes of 
the stomach, of the nasal cavities, or of the lungs ; the skin, not un- 
commonly that of the mammse, probably on account of their intimate 
sympathetic relation with the uterine organs ; from the surface of an 
ulcer ; or from hemorrhoids. It is a noteworthy fact that in all these 
cases the discharge occurs in situations where its external escape can 
readily take place. This strange deviation of the menstrual discharge 
may be taken as a sign of general ill-health, and it is usually met with 
in delicate young women of highly mobile nervous constitution. It 
may, however, begin at puberty, and it has even been observed during 
the whole sexual life. The recurrence is regular, and always in connec- 
tion with the menstrual nisus, although the amount of blood lost is much 
less than in ordinary menstruation. 

Cessation of Menstruation. — After a certain time changes occur, 
showing that the woman is no longer fitted for reproduction ; menstru- 
ation ceases, Graafian follicles are no longer matured, and the ovary be- 
comes shrivelled and wrinkled on its surface. Analogous alterations 
take place in the uterus and its appendages. The Fallopian tubes atro- 
phy, and are not unfrequently obliterated. The uterus decreases in size. 
The cervix undergoes a remarkable change, which is readily detected on 
vaginal examination; the projection of the cervix into the vaginal 
canal disappears, and the orifice of the os uteri in old women is 
found to be flush with the roof of the vas^ina. In a laro-e number 
of cases there is, after the cessation of menstruation, an occlusion both 
of the external and internal os; the canal of the cervix between them, 
however, remains patulous, and is not unfrequently distended with a 
mucous secretion. 

The age at which menstruation ceases varies much in different women. 
In certain cases it may cease at an unusually early age, as between thirtv 
and forty years, or it may continue far beyond the average time, even up 
to sixty years; and exceptional, though perhaps hardly reliable, instamvs 
are recorded in which it has continued even to eighty or iiinetv vears. 
These are, however, strange anomalies, which, like cases of unusually 
})recocious, menstruation, cannot be considered as having anv bearino- on 
the general rule. INIost cases of so-called protracted menstruation will 
be found to be really morbid losses oi' blo(xl depending on nialiunant or 
other forms of organic disease, the existence of which, under such cir- 
cumstances, should always be suspected. 

In this country menstruation usually ceases between fortv and fiftv 
years of age. Raciborski says that the largest number oi' leases of cH?ssii- 
tion are met with in the fortv-sixth year. It is iivnorallv said that 



94 ORGANS CONCERNED IN PARTURITION. 

women who commence to menstruate when very young cease to do so 
at a comparatively early age, so that the average duration of the func- 
tion is about the same in all women. Cazeaux and Raciborski, whose 
opinion is strengthened by the observations of Guy in 1500 cases/ 
think, on the contrary, that the earlier menstruation commences the 
longer it lasts, early mensturation indicating an excess of vital energy 
which continues during the whole childbearing life. Climate and other 
accidental causes do not seem to have as much effect on the cessation as 
on the establishment of the function. It does not appear to cease 
earlier in warm than in temperate climates. The change of life is 
generally indicated by irregularities in the recurrence of the discharge. 
It seldom ceases suddenly, but it may be absent for one or more periods, 
and then occur irregularly ; or it may become profuse or scanty until 
eventually it entirely stops. The popular notions as to the extreme 
danger of the menopause are probably much exaggerated, although it 
is certain that at that time various nervous phenomena are apt to be 
developed. So far from having a prejudicial effect on the health, how- 
ever, it is not an uncommon observation to see an hysterical woman, 
who has been for years a martyr to uterine and other complaints, appar- 
ently take a new lease of life when her uterine functions have ceased 
to be in active operation ; and statistical tables abundantly prove that the 
general mortality of the sex is not greater at this than at any other 
time. 

1 3Ied. Times and Gaz., 1845. 



PART II. 

PREGNANCY. 



CHAPTER I. 

CONCEPTION AND GENEKATION. 

Generation in the human female, as in all mammals, requires 
the congress of the two sexes, in order that the semen, the male ele- 
ment of generation, may be brought into contact with the ovule, the 
female element of generation. 

The semen secreted by the testicle of an adult male is a viscid, opal- 
escent fluid, forming an emulsion when mixed with water, and having 
a peculiar faint odor, which is attributed to the secretions which are 
mixed with it, such as those from the prostate and Cowper's glands. 
On analysis it is found to be an albuminous fluid, holding in solution 
various salts, principally phosphates and chlorides, and an animal sub- 
stance, spermatin, analogous to fibrin. Examined under a magnify- 
ing power of from 400 to 500 diameters, it consists of a transparent and 
homogeneous fluid, in which are floating a certain number of granules 
and epithelial cells derived from the secretions mixed with it, and cer- 
tain characteristic bodies, the spermatozoa, which are developed from 
the sperm-cells, and which form its essential constituents. The sperm- 
cells are those occupying the tubuli seminiferi of the testicle. Seveml 
kinds of sperm-cells are described which receive their name from the 
position they occupy with regard to the lumen of the tubule (Fig. 44). 
The cells which are next to the wall of tlie tubule are called the outer 
or lining cells. They are more or less flattened in form, and are situa- 
ted on a distinct basement membrane. Internal to this layer is another, 
consisting of round cells, the nuclei of which are in a state (~>f prolifera- 
tion : this is the intermediate layer. Between this and the himen of the 
tubule are a number of cells irregular in shape, amongst which are im- 
bedded the heads of i\\Q spermatozoa, the tails of whicli project into the 
lumen. The spermatozoa are tliought to arise from the middle or \n'o- 
liferating layer in the following manner : the nuclei of the sperm-cells 
proliferate, and from their subdivisions arise the heads of the sperma- 
tozoa, the bodies of which originate from the protoplasm o^ the cells. 
By the decom})osition of the substance in which the heads o^ the sperm- 
atozoa are imbedded the containetl spermatozoa become libenutxl and 
move about freely in the seminal fluid. As seen luuler the microsco]H\ 



96 



PEEGXAyCY. 



the spermatozoa, which exist in heahhy semen in enormous numbers, 
present the appearance of minute particles not unlike a tadpole in 
shape. The head is oval and flattened, measuring about iqI^^^ of an 
inch in breadth, and attached to it by a short intermediate portion is a 
delicate filamentous expansion or tail, which tapers to a point so fine 
that its termination cannot be seen by the highest powers of the micro- 
scope. The wliole spermatozoon measures from ^^ to -g^ of an 
inch in length. The spermatozoa are observed to be in constant 



m length. 



Fig. 44. 




Section of Parts of Three Seminiferous Tubules of the Eat. 

a. With the spermatozoa least advanced in development, b. More advanced, c. Containing fully -developed 
spermatozoa. Between the tubules are seen strands of interstitial cells and lymph-spaces, (From a 
preparation by Mr. A. Frazer.) 



motion, sometimes very rapid, sometimes more gentle, which is sup- 
po.sed to be the means by which they pass upward through the female 
genital organs. They retain their vitality and power of movement for 
a considerable time after emission, provided the semen is kept at a tem- 
perature similar to that of the body. Under such circumstances they 
have been observed in active motion from forty-eight to seventy-two 
hours after ejaculation, and they have also been seen alive in the testicle 
as long as twenty-four hours after death. In all probability they con- 
tinue active much longer within the generative organs, as many physi- 
ologists have observed them in full vitality in bitches and rabbits seven 
or eight days after copulation. The recent experiments of Haussman, 
however, show that they lose their power of motion in the human 
vagina within twelve hours after coitus, although they doubtless re- 
tain it longer in the uterus and Fallopian tubes. Abundant leucorrheal 
discharges and acrid vaginal secretions destroy their movements, and 
may thus cause sterility in the female. On account of their mobility, 
the spermatozoa were long considered to be independent animalcules — a 
view which is by no means exploded, and has been maintained in mod- 
ern times by Pouchet, Joulin, and other writers, while Coste, Robin, 



CONCEPTION AND GENERATION. 97 

Kolliker, etc. liken their motion to that of ciliated epithelium. There 
can be no doubt that the fertilizing power of the semen is due to the 
presence of the spermatozoa, although some of the older physiologists 
assigned it to the spermatic fluid. The former view, however, has been 
conclusively proved by the experiments of Prevost and Dumas, who 
found that on carefully removing the spermatozoa by filtration the 
semen lost its fecundating properties. 

Sites of Impregnation. — There has been great difference of opinion 
as to the part of the genital tract in which the spermatozoa and the ovule 
come into contact, and in which impregnation, therefore, occurs. Sperm- 
atozoa have been observed in all parts of the female genital organs in 
animals killed shortly after coitus, especially in the Fallopian tubes, and 
even on the surface of the ovary. The phenomena of ovarian gesta- 
tion, and the fact that fecundation has been proved to occur in certain 
animals within the ovary, tend to support the idea that it may also occur 
in the human female before the rupture of the Graafian follicle. In 
order to do so, however, it is necessary for the spermatozoa to penetrate 
the proper structure of the follicle and the epithelial covering of the 
ovary ; and no one has actually seen them doing so. Most probably the 
contact of the spermatozoa and the ovule occurs very shortly after the 
rupture of the follicle and in the outer part of the Fallopian tubes. 
Coste maintains that unless the ovule is impregnated it very rapidly 
degenerates after being expelled from the ovary, partly by inherent 
changes in the ovule itself, and partly because it then soon becomes 
invested by an albuminous covering which is impermeable to the 
spermatozoa. He believes, therefore, that impregnation can only 
occur either on the surface of the ovary or just within the fimbri- 
ated extremity of the tube. 

Mode in which the Ascent of the Semen is Effected. — The 
semen is probably carried upward chiefly by the inherent mobility of 
the spermatozoa. It is believed by some that this is assisted by other 
agencies : amongst them are mentioned the peristaltic action of the 
uterus and Fallopian tubes ; a sort of capillary attraction effected when 
the walls of the uterus are in dose contact, similar to the movement of 
fluid in minute tubes ; and also the vibratile action of the cilia of the 
epithelium of the uterine mucous membrane. The action of the latter is 
extremely doubtful, for they are also supposed to effect the descent of 
the ovule, and they can hardly act in two opposite ways. The move- 
ment of the cilia being from within outward, it Avould certainly ojipose 
rather than favor the progress of the spermatozoa. It must, theretbre, 
be admitted that they ascend chiefly through their own powers of 
motion. They certainly have this j)ower to a remarkable extent, for 
there are numerous cases on record in which impregnation has ocinnuvil 
without penetration, and even when the hymen was quite entire, and in 
which the semen has simply been deposited on the extericn- of the 
vulva: in such cases, which are fiir from uncommon, the spermatozoa 
must liave found their way through tlie whole length of the vauina. 
It is probable, liowcver, that under tu'dinarv circumstances the pass;ige 
of the spermatic fluid into the uterus is facilitated by changes which 
take place in the cervix diu'ing the sexual orgasm, in the course of 
7 



98 



FEEGNAXCY. 



Fig. 45. 




which the os uteri is said to dilate and close again in a rhythmical 

manner.^ 

Impregnation. — The precise method in which the spermatozoa 

effect impregnation was long a matter of doubt. It is now, however, 

certain that they actually penetrate the ovule and reach its interior. 

This has been conclusively proved by the observations of Barry, 

Meissner, and others, A^ho have seen the 
spermatozoa within the external membrane 
of the ovule in rabbits (Fig. 45). In some 
of the invertebrata a canal or opening exists 
in the zona pellucida through which the 
spermatozoa pass. No such aperture has 
yet been demonstrated in the ovules of 
mammals, but its existence is far from 
improbable. According to the observations 
of I^ewport, several spermatozoa penetrate 
the zona pellucida aud enter the ovule ; and 
the greater the number that do so the more 
^ T> ^.u•. . ■ • certain fecundation becomes. In the lower 

Ovum of Rabbit containing • i i p • n i - ^ 

Spermatozoa. auunals the tusion ot the spermatozoa with 

1. Zona pellucida. 2. The germs, con- the substaucc of the vclk lias bccu observcd I 

sisting of two large cells, several ni,i i«'ii i f 

smaller cells, and spermatozoa. and although Similar phenomena have not 

been observed in the human ovum, there is 
not any doubt but that the further development of the ovum is due to 
the union of the spermatozoon with the female element. 

The length of time which lapses before the fecundated ovule arrives 
in the cavity of the uterus has not yet been ascertained, and it probably 
varies under different circumstances. It is knowm that in the bitch it 
may remain, eight or ten days in the Fallopian tube, in the guinea-pig 
three or four. In the human female the ovum has never been discov- 
ered in the cavity of the uterus before the tenth or twelfth day 
after impregnation. 

The changes w^hich occur in the human ovule immediately before and 
after impregnation, and during its progress through the Fallopian tube, 
are only known to us by analogy, as, of course, it is impossible to study 
them by actual observation. We are in possession, however, of accu- 
rate information of what has been made out in the lower animals, and 
it is reasonable to suppose that similar changes occur in man. Imme- 
diately after the ovule has pa&sed into the Fallopian tube it is found to 
be surrounded by a layer of granular cells, a portion of the lining 
membrane of the Graafian follicle, w^hich was described as the discus 
proligerus. As it proceeds along the tube these surrounding cells dis- 
appear, partly, it is supposed, by friction on the Avails of the tube, aud 
partly by being absorbed to nourish the ovule. Be this as it may, 
before long they are no longer observed, and the zona pellucida forms 
the outermost layer of the ovule. When the ovule has advanced some 
distance along the tube, it becomes invested with a covering of albumi- 
nous material, w^hich is deposited around it in successive layers, the 
thickness of Avhich varies in different animals. It is very abundant in 

^ Bow do the Spermatozoa Enter the Uterus? By J. Beck, M. D. 




CONCEPTION AND GENERATION 99 

birds, in whom it forms the familiar white of the egg. In some ani- 
mals it has not been detected, so that its presence in the human ovule 
is uncertain. Where it exists it doubtless contributes to the nourish- 
ment of the ovule. Coincident with these changes is the disai)pear- 
ance of the germinal vesicle. At the same time iha yelk contracts and 
becomes more solid, retiring from close contact with the zona pellu- 
cida, and thus leaving a space between 
the outer edge of the yelk and the vitel- i^'^t^- 46. 

line membrane, which in some animals is 
filled with a transj^arent liquid. Coinci- 
dent with the shrinking of the yelk, a 
small granular mass of a rounded form 
is extruded from the yelk into the clear 
space beneath the zona pellucida. At a 
later period another similar mass is extru- 
ded. These are the j)olar globules (Fig. 
46), and it is thought from observations 
on the invertebrata that they arise from 

the germinal vesicle, the remains of Formation of the " Polar Globule." 
which give origin to a new nucleus, l. zona pellndda, containing sperma- 

which is known as the female pronucleus. veSe. 5. The poll/giobuie. ^^™*°^ 
These changes occur in all ovules, 

whether they are impregnated or not, but if the ovule is not fecundated 
no further alterations occur. Supposing impregnation has taken place 
by the entrance of a spermatozoon within the zona pellucida of the 
ovule, a second nucleus is formed by the penetration of the spermato- 
zoon within the yelk, where it loses its tail and becomes transformed 
into a granular body, the male pronucleus. After a time the male and 
female pronuclei approach one another, and finally fuse to form a new 
nucleus, and the ovum then receives the name of the blastosphere, or 
first segmentation-sphere. After this occurs the very peculiar phenom- 
enon known as the cleavage of the yelk, which results in the formation 
of the layer of cells from which the foetus is developed. The segmen- 
tation of the yelk (Fig. 47) occupies in mannnals the whole of its sub- 
stance. In birds the cleavage is confined to a small area of the yolk 
called the cicatricula or blastoderm. Hence the term holoblastic has 
been applied to the ova of mammals, meroblastic to those of birds. It 
divides at first into two halves, and at the same time the new or first 
segmentation-nucleus becomes constricted in its centre, and separates 
into two ])ortions, one of which forms a centre for each of the halves 
into which the yelk has divided. Each of those immodiatoly divides 
into two, as does its contained portion of the nucleus, and so on in rapid 
succession until i\\Q whole yelk is divided into a number of divisions, 
€ach of which consists of a clumj) of nucleated protoplasm. 

By these continuous dichotomous divisions the whole yolk is iornu\i 
into a granular mass, which, from its supposed rosombhmco to a mul- 
berry, has been named the iniirifonn bodif. AVhon the subdivision of 
the yelk is com})leted its se'|>arato parts become converted into a number 
of cells, each of which consists of a mass of granular protoplasm. 
These cells unite by their edges to form a continuous lining (Fig. 48\ 



100 



PREGNANCY. 



which, through the expansion of the muriform body by fluid which 
forms in its interior, is distended until it forms a lining to the zona pel- 
lucida. This is the blastodermic membrane, from which the foetus is 
developed. By this time the ovum has reached the uterus ; and before 
proceeding to consider the further changes which it undergoes it will 



Fig. 47. 




Sections of the Ovum of the Rabbit during the Later Stages of Segmentation, showing the 
formation of the blastodermic vesicle. (After E. v. Beneden.) 

a, Section showing the enclosure of entomeres, ent., hy ectomeres, ec<., except at one spot — the blastopore. 
b. More advanced stage, in which fluid is beginning to accumulate between the entomeres and 
ectomeres, the former completely enclosed, c. The fluid has much increased, so that a large space 
separates entomeres from ectomeres, except at one part. f7. Blastodermic vesicle, its wall formed 
of a layer of ectodermic cells, with a patch of entomeres adhering to it at one part, z.p., ect., ent. As 
before. 

be well to study the alteration which the stimulus of impregnation has 
set on foot in the mucous membrane of the uterus in order to prepare it 
for the reception and growth of its contents. 

Even before the ovum reaches the uterus the mucous membrane 
becomes thickened and vascular, so that its opposing surfaces entirely 
fill the uterine cavity. These changes may be said to be the same in 
kind, although more marked and extensive in degree, as the alterations 
Avhich take place in the mucous membrane in connection with each 
menstrual period. The result is the formation of a distinct membrane, 
which affords the ovum a safe anchorage and protection until its con- 
nections with the uterus are more fully developed. After delivery this 
membrane, which is by that time quite altered in appearance, is at least 



CONCEPTION AND GENERATION. 



101 



partially thrown off with the ovum ; on which account it has received 
the name of the decidua caduca. 

The decidua consists of two principal portions, which in early preg- 
nancy are separated from each other by a considerable interspace, which 
is occupied by mucus. One of these, called the decidua vera, lines 
the entire uterine cavity, and is, no doubt, the original mucous lining 
of the uterus greatly hypertrophied. The second, the decidua reflexa, 
is closely applied round the ovum, and it is probably formed by the 
sprouting of the decidua vera around the ovum at the point on which 
the latter rests, so that it eventually completely surrounds it. As the 
ovum enlarges the decidua reflexa is necessarily stretched until it comes 
everywhere in contact with the decidua vera, with which it firmly 

Fig. 48. 




Formation of the Blastodermic Membrane from the Cells of the Muriform Body. (After 

Joulin.) 

1. Layer of albuminous material surrounding 2. The zona pellucida. 



unites. After the third month of pregnancy true union has occurred, 
and the two layers of decidua are no longer separate. The decidua scr- 
otina, which is described as a third portion, is merely that part of the 
decidua vera on which the ovum rests, and where the* placenta is event- 
ually developed ; it is characterized by its extreme vascularity, which 
serves the purpose of supplying nutriment to the fivtus through the 
capillaries of the fiietal placenta. 

It is needless to refer to the various views which have been held bv 
anatomists as to the structure and formation of the decidua. That 
taught by John Hunter was long believed to be correct, and down to a 
recent date it received the adherence of most physiologists. lie believed 
the decidua to be an infiammatory exudation which, on aci-oiint of the 
stimulus of pregnancy, was thrown out all over thecavitv oi' the uterus, 
and soon formed a distinct lining membrane to it. When the ovum 
reached the uterine orifice of the Fallopian tube it found its entrance 
barred by this new membrane, which accordingly it pushed botoiv it. 



102 



PREGNANCY. 



This separated 23ortion formed a covering to the ovum, and became the 
decidiia reflexa, while a fresh exudation took place at that portion of the 
uterine wall which was thus laid bare, and this became the decidua ser- 
otina. William Hunter had much more correct views of the decidua, 
the accuracy of which was at the time much contested, but which have 
recently received full recognition. He describes the decidua in his 
earlier Avritings as an hypertrophy of the uterine mucous membrane 
itself — a view which is now held by all physiologists. 

When the decidua is first formed it is a hollow triangular sac lining 
the uterine cavity (Fig. 49), and having three openings into it — those 

Fig. 49. 




Aborted 0\mn of about Forty Days, showing the triangular shape of the decidua (which is 
laid open), and the aperture of the Fallopian tube. (After Coste) 



of the Fallopian tubes at its upper angles, and one, corresponding to 
the internal os uteri, below. If, as is generally the case, it is thick and 
pulpy, these openings are closed up and can no longer be detected. In 
early pregnancy it is well developed, and continues to grow up to the 
third month of utero-gestation. After that time it commences to 
atrophy, its adhesion with the uterine walls lessens, it becomes thin and 
transparent, and is ready for expulsion when delivery is effected. 
When it is most developed a careful examination of the decidua 
enables us to detect in it all the elements of the uterine mucous mem- 
brane greatly hypertrophied. Its substance chiefly consists of large 
round or oval nucleated cells and elongated fibres, mixed with the 
tubular uterine glands, Avhich are much elongated, lined by columnar 
ciliated epithelial cells, and contain a small quantity of milky fluid- 
According to Friedlander, the decidau is divisible into two layers : the 
inner being formed by a proliferation of the corpuscles of the subepi- 



CONCEPTION AND GENERATION. 



103 



thelial connective tissue of the mucous membrane ; the deeper, in con- 
tact with the uterine walls, out of flattened or compressed gland-ducts. 
In an early abortion the extremities of these ducts may be observed by 
a lens on the external or uterine surface of the decidua, occupying the 
summit of minute projections separated from each other by depressions. 
If these projections be bisected, they will be found to contain little 
cavities filled with lactescent fluid, which were first described by Mont- 
gomery of Dublin, and are known as 3Iontgomery\s cupn. They are 
in fact the dilated canals of the uterine tubular glands. On the inter- 
nal surface of such an early decidua a number of shallow depressions 
may be made out, which are the open mouths of these ducts. 

The decidua vera is highly vascular, and its vascularity persists till 
after the seventh month of pregnancy; the decidua reflexa is only vas- 
cular during the early part of pregnancy, depending for its vascularity 
chiefly on the villi of the chorion, and hence losing this with their 
atrophy. 

When the ovum reaches the uterine cavity it soon becomes imbedded 
in the folds of the hypertrophied mucous membrane, which almost 
entirely fills the uterine cavity. As a rule, it is attached to some 
point near the opening of a Fallopian tube, the swollen folds of 
mucous membrane preventing its descent to the lower part of the 
uterus; in exceptional circumstances, however — as in women who 
have borne many children and have a more than usually dilated uterine 
cavity — it may fix itself at a point much nearer the internal os uteri. 
According to the now generally accepted opinion of Coste, the mucous 
membrane at the base of the ovum soon begins to sprout around it, 
and gradually extends until it eventually covers the ovum (Figs. 50- 
52), and forms the decidua reflexa. Coste describes, under the name 



FjCx. 50. 



Fig. 51. 



Fig. 52. 






Formation of Decidua. 

(The decidua is colored 
l)lack ; the ovum is r(>p- 
resented as eiiKiii;c'd be- 
tween two i)roJecting foUls 
of meiJibrane.) 



I'rojeetini: Folds of Mom- 
briuu\m-o\viug upiirouud 
the Ovum. 



Showing; Ovum oouiplotolv 
surrounded bv the Decidua 
Kctiexu. 



of the nmhUicus, a small, depression at the most prominent part ot' the 
ovum, which he considers to be the indication of the point where 
the cK)sure of the decidua rellexa is ell'ecteil. There are some objections 



10^ PREGNANCY. 

to this theory, for no one has seen the decidua reflexa incomplete and 
in the process of formation ; and on examining its external surface — 
that is, the one farthest from the ovum — its microscopical appearance 
is identical with that of the inner surface of the decidua vera. To 
meet these difficulties, ^yeber and Goodsir, whose views have been 
adopted by Priestley, contended that the decidua reflexa is " the pri- 
mary lamina of the mucous membrane, which, when the ovum enters 
the uterus, separates in two-thirds of its extent from the layers beneath 
it to adhere to the ovum ; the remaining third remains attached and 
forms a centre of nutrition." According to this view, the decidua 
vera would be a subsequent growth over the separated portion, and 
the decidua serotina the portion of the primary lamina which remained 
attached. In this way the fact of the opposed surfaces of the decidua 
vera and reflexa being identical in structure would be accounted for. 
The difficulty which this theory is intended to meet does not seem so 
great as is supposed, for if, as is likely, it is only the epithelial or 
internal surface of the mucous membrane which sprouts over the 
ovum, and not its deeper layers, the facts of the case would be suf- 
ficiently met by Coste's view\ 

Up to the third month of pregnancy the decidua reflexa and vera are 
not in close contact, and there may even be a considerable interspace 
between them, which sometimes contains a small quantity of mucous 
fluid called the hydroperione. This fact may account for the curious 
circumstance — of w^hich many instances are on record — that a uterine 
sound may be passed into a gravid uterus in the early months of preg- 
nancy without necessarily producing abortion, and also for the occasional 
occurrence of menstruation after conception (Figs. 53 and 81). Eventu- 

FiG. 53. 




An Ovum removed from Uterus, and Part of the Decidua Vera cut away. (After Coste.) 

a. Decidua vera, showing the follicles opening on its inner surface, h. Inner extremity of Fallopian tube. 

c. Flap of decidua reflexa. d. Ovum. 

ally, by the grow^th of the ovum, the decidua reflexa comes closely into 
contact with the vera, and the two become intimately blended and 



CONCEPTION AND GENERATION. 105 

inseparable. The inner surface of the decidua reflexa blends with the 
outer surface of the chorion, so that at birth the decidua vera, the decidua 
reflexa, and the chorion are represented by one membrane. 

As pregnancy advances the decidua alters in appearance and becomes 
fibrous and thin. In the later months of utero-gestation fatty degenera- 
tion of its structure commences, its vessels and glands are obliterated, 
and its adhesion to the uterine walls is lessened, so as to prepare it for 
separation. As we shall subsequently see, this fatty degeneration was 
assumed by Simpson to be the determining cause of labor at term. 
After the eighth month thrombi form in the veins lying underneath 
the decidua serotina, and at the end of pregnancy they are descril)ed by 
Leopold ^ as having become, to a great extent, obliterated. This, he 
supposes, may have some effect in inducing the contractions of the 
uterus in labor. 

It was long believed that the entire decidua was thrown off after 
labor, leaving the muscular coat of the uterus bare and denuded, and 
that a new mucous membrane was formed during convalescence. 
According to Robin,^ whose views are corroborated by Priestley, no such 
denudation of the muscular tissue of the uterus ever occurs, but a por- 
tion of the decidua always remains attached after delivery. After the 
fourth month of pregnancy they believe that a new mucous membrane 
is formed under the decidua, which remains in a somewhat imperfect 
€ondition till after delivery, when it rapidly develops and assumes the 
proper functions of the mucous lining of the uterus. Robin also 
believes that that portion of the decidua which covers the placental site, 
the so-called decidua serotina, is not thrown off witli the membranes, 
like the decidua vera and reflexa, but remains attached to the uterine 
walls, a thin layer of it only being expelled with the placenta, on which 
it may be observed. Duncan ^ entirely dissents from these views, and 
does not admit the formation of a new mucous membrane during the 
later months of utero-gestation. He believes that the greater })ortion 
of the decidua is thrown off, but that part remains, and from this the 
fresh mucous membrane is developed. This view is similar to that of 
Spiegelberg, who holds that the portion of the decidua that is expelled 
is the more superficial of the two layers described by Friedliinder, com- 
posed chiefly of the epithelial elements, while the deeper or glandular 
layer remains attached to the walls of the uterus. From the epithelium 
of the glands a new epithelial layer is rapidly developed after delivery. 
Leopold * has shown that the uterine mucous membrane is completely 
re-formed within six Aveeks after delivery, and that its regeneration is 
sometimes completed as early as the end of the third week. This theory 
bears on the well-known analogy of the uterus after delivery to the 
stump of an amputated limb — an old simile principally based on the 
erroneous theory that the whole muscular tissue of the uterus was laitl 
bare. This, as we have seen, is not the case, but the simile so far holds 

^ Arch.f. G>in., 1887, Bd. xi. lift. 3, S. 443 : "Stiulion iibor die rtorus-schloimhaiu 
wiilirend ]Menstriiation." , 

2 Mcmoiiri^dc PAcad. Imp. dc ^f^'d., 18()1. 

^ Ri'sca relics in Ohxtcfric!^, \). 1S() ,7 >•,•(/. 

^ Arch. /'. Oi/n., 1877, Bd. xii. lift. 2. S. IGD. 



106 



PREGNANCY. 



good in that the mucous lining is deprived of its epithelial covering; 
and this fact, together with the existence of numerous open veins on the 
interior of the uterus, readily explains the extreme susceptibility to 
septic absorption which forms so peculiar a characteristic of the puer- 
peral state. 

Before we commenced the study of the decidua we had traced the 
impregnated ovum into the uterine cavity, and described the formation 
of the blastodermic membrane by the junction of the cells of the muri- 
form body. We must uoav proceed to consider the further changes 
which result in the development of the foetus and of the membranes 
that surround it. It would be quite out of place in a work of this 
kind to enter into the subject of embryology at any length, and we must 
therefore be content with such details as are of importance from a 
practical point of view. 

The blastodermic membrane, which forms a complete spherical 
lining to the ovum between the yelk and the zona pellucicla, soon 
divides into two layers, of which the external is called the ejnblast, the 
internal the hypoblast, and between these is subsequently developed a 
third layer, known as the mesoblast From these three layers are 
formed the entire foetus : the epiblast giving origin to the central ner- 
vous system, to the superficial layer of the skin, and aiding in formation 
of the organs of special sense and of the amnion ; the hypoblast forming 
the epithelial lining membrane of the alimentary and respiratory tracts 
and of the tubes and glands in connection with them, and helping in the 
development of the yelk-sac ; the mesoblast giving rise to the skeleton, 
the muscles, the connective tissues, the vascular system, the genito-uri- 
nary organs, and taking part in the formation of all the membranes. 

Almost immediately after the separation of the blastodermic mem- 
brane into la vers one part of it becomes thickened by the aggregation, 
of cells, and is called the area germhiativa. This is at first round and 

then oval in shape, and at it& 
Fig. 54. margin the first indication of the 

embryo may be detected in the 
form of a narrow thickening, the 
primitive trace. This becomes elon- 
gated and stretches in a strap-like 
form along the centre of the 
germinal area ; it is considered by 
Balfour to represent the blastopore 
of animals, the ova of which 
undergo invagination to form a 
gastrula. Surround ing it are some 
cells more translucent than those 
of the rest of the area germinativa, 
and hence called the area pellucida 
(Fig. 54). In front of the primi- 
tive trace two elevated ridges soon 
arise, the lamince dorsales, which include between them a groove, the 
medullary groove, and gradually unite posteriorly to form a cavity 
within which the cerebro-spinal axis is subsequently developed. The 




Diagram of Area Germinativa, showing the 
primitive trace and area pellucida. 



CONCEPTION AND GENERATION. 



107 



medullary groove as it grows backward overlaps the primitive trace, 
which disappears. The embryo is differentiated from the rest of the 
blastoderm by a fold anteriorly, which is called the cephalic or head- 
fold. Another fold afterward ai)pears posteriorly, which is called the 
caudal or tail-fold. Laterally, folds also arise. These folds all tend to 
grow toward the centre of the under surface of what will be the 
embryo. 

The mesoblastic layer of the blastoderm, except that part which forms 
the axis of the embryo, splits into an upper layer, the somatopleure, 
which is beneath the epiblast, and a lower layer, the splanchnopleure, 
which lies upon the hypoblast. The space formed by this cleavage of 
the mesoblast is called the pleuro-peritoneal cavity. The somatopleure 
is engaged in the formation of the body-walls of the embryo. The 
splanchnopleure forms the walls of the alimentary tract. 

Pormation of the Amnion. — Processes arise from the somatopleure 
anteriorly, posteriorly, and laterally, which gradually arch over the 
dorsal surface of the foetus, until 
they meet each other and form a 
complete envelope to it. At the 
ventral surface these processes are 
separated by the whole length of 
the embryo, but they here also gradu- 
ally approach each other, and eventu- 
ally surround what is subsequently 
the umbilical cord, and blend with 
the integument of the foetus at the 
point of its insertion. In this way 
is formed the amnion (Fig. 55), con- 
sisting of two layers : the internal, 
derived from the epiblast, is formed 
of tessellated epithelial cells ; the 
external, arising from the mesoblast, • 
is formed of cells like those of young 
connective tissue. Before the folds 
of the amnion unite the free edge of 

each is bent outward and spread around the ovum immediatelv within 
the zona pellucida, forming a lining to it, termed by Turner \\\esuhzonal 
membrane^ which is connected with the development of the chorion. 
In man this reflected layer, or fake amnion, consists onlv of epiblast, 
but in some other animals it is probably formed from both the meso- 
blast and the epiblast, like the true anniion. The amnion is the most 
internal of the membranes surrounding the fix^tus, and will prosentlv be 
studied more in detail. It soon becomes distended with fiiiid. the liquor 
amnii, and as this increases in amount it separates the amnion more and 
more from the foetus. 

During this time the innermost layer of the blastodermic* membrane 
or hypoblast is also developing two projections at either extremitv oi^ the 
frt^tus, and these gradually 'ap[)roaeh each other anteriorlv. As the hvpo- 
blast is in contact with the yelk, when tlu\^e meet they have the etVeet oi^ 
dividing the yelk into two portions. One, and the smaller ot' the two. 




\^^\y-\S*' 



Lc--^ 



Development of the Amnion. 
Vitelline membrane. 2. External layer of 
blastodermic membrane. 3. Internal "layers 
forming the umbilical vesicle. 4. Umbilical 
vessels. 5. Projections forming amnions. 
6. Embryo. 7. Allantois. 



108 



PREGNANCY. 



forms eventaally the intestinal canal of tlie foetus; the other, and much 
the larger, contains the greater portion of the yelk, and forms the ephem- 
eral structure known as the unibilical vesicle, from which the foetus 
derives most of its nourishment during the early stage of its existence. 
Its communication with the abdominal cavity of the foetus is through 
the constricted portion at the point of division called the vitelline duct 
(Fig. 56). An artery and vein, the omphalo-mesentericy ramify on the 
vesicle and its duct. 

Fia. 56. 




1. Exo-chorion. 



2. External layer of blastodermic membrane. 3. Umbilical vesicle. 
5. Amnion. 6. Embryo. 7. Allantois increasing in size. 



4. Its vessels. 



Fig. 57. 



As the amnion increases in size it pushes back the umbilical vesicle 
toward the external membrane of the ovum, between which and the 
amnion it lies (Fig. 57) ; and when the allantois is 
developed it ceases to be of any use, and rapidly 
shrinks and dwindles away. In most mammals 
no trace of it can be found after the fourth month 
of utero-gestation ; in some, including the human 
female, it is said to exist as a minute vesicle at the 
placental end of the umbilical cord at the full 
period of pregnancy. The umbilical vesicle is 
filled with a yellowish fluid, containing many 
oil and fat-globules, similar to the yelk of an 

The Allantois. — Somewhere about the twen- 
tieth day after conception a small vesicle is 
formed toward the caudal extremity of the foetus, 
which is called the cdlantois. This membrane in 
mammals is important, as it forms the greater part 
of the foetal placenta, a small portion of it remain- 
ing inside the body permanently as the bladder. It 
begins as a diverticulum from the lower part of the intestinal canal, 
and is hence formed externally by the splanchnopleural layer of the 
mesoblast, whilst internally it is lined by the hypoblast. It is at first 
spherical, but it rapidly develops and becomes pyriform in shape, while 




An Embryo 
twentv-five 



(After Coste.) 



open 

a. Chorion, b. Amnion 

c. Cavity of chorion. 

d. Umbilical vesicle. 

e. Pedicle of allantois. 
/. Embryo. 



CONCEPTION AND GENERATION. 



109 



by a process of constriction similar to that which occurs in the vitellus 
to form the umbilical vesicle it becomes divided into two parts^ com- 
municating with each other, the smaller of them being eventually 
developed into the urinary bladder. The larger portion, leaving the 
abdominal cavity along with the vitelline duct, rapidly grows until it 
comes into contact with the most external ovular membrane, the chorion, 



Fig. 58. 




1. Exo-chorion. 2. External layer of the blastodermic membrane. 3. Allan tois. 4. Umbilical vesicle. 
5. Amnion. 6. Embryo. 7. Pedicle of allautois. 

over the inner surface of which it spreads. This part consists chiefly of 
mesoblastic tissue, the hypoblast only passing to the end of the stalk of 
the allantois, and not following the mesoblast as it spreads over the 
inner surface of the chorion. The area of the chorion over which the 
allantois spreads varies in different animals : in man it spreads over the 
entire surface, but in the rabbit it only occupies one-third of the chorion, 
the remaining two-thirds being occupied by the yelk-sac. This varying 
distribution of the allantois helps to differentiate the placentation of man 
and the apes from that of rodents. In the mesoblastic tissue of the 
allantois vessels soon develop — namely, the two umbilical arteries, 
derived from the abdominal aorta, and two umbilical veins, one of 
which subsequently disappears; these, along with the vitelline duct and 
the pedicle of the allantois, form the umbilical cord. The main and 
very important function of the allantois, therefore, is to carry the fa^tal 
vessels up to the inner surface of the subzonal membrane. Besides 
this purpose, the allantois at a very early ])eriod may receive the excre- 
tions of the foetus and serve as an excrementitious organ. According 
to Cazeaux, scarcely a trace of the allantois can be seen a few days after 
its formation. Its lower part or pedicle, however, long remains dis- 
tinct, and forms part of the umbilical cord; and traces of it may be 
found even in adult life in the form of the urachus. which is really the 
dwindled pedicle and forms one of the ligaments of the bladder. The 
cavity of the allantois in 'the human species is continetl chietiv to that 
part which lies within the body of the llvtus; it is seldom pei-^isteut 
farther than the stalk of the allantois. 



110 PREGNANCY. 

Between the chorion and amnion is often found an albuminous fluid, 
with minute filamentous processes traversing it, called by Yelpeau the 
corps redicule, which is not met with until the allantois comes into con- 
tact with the chorion, and which seems to be formed out of the tissues 
of that vesicle. It is analogous to the so-called Wharton's jelly found 
in the umbilical cord. AY hen first formed it is highly vascular, but the 
vessels entirely disappear after the placenta is formed, and the remain- 
der of the chorionic villi atrophy. Sometimes it exists in considerable 
quantities, and, should the chorion rupture at the end of pregnancy it 
may escape and give rise to an erroneous impression that the liquor 
amnii has been discharged (Fig. 59). 

Before proceeding to consider the foetal envelopes more at length, it 
may be useful to recapitulate the structures already alluded to as form- 
ing the ovum. In this we find — 

1. The embryo itself. 

2. A fluid, the liquor amnii, in which it floats. 

3. The amnion, a purely foetal membrane surrounding the embryo 
and containing the liquor amnii. 

4. The umbilical vesicle, containing the greater portion of the yelk, 
serving as a source of nutrition to the early embryo through the 
vitelline duct, and on which ramify the omphalo-mesenteric vessels. 

5. The allantois, a vesicle proceeding from the caudal extremity of 
the embryo, spreading itself over the interior of the ovum, and serving 
as a channel of vascular communication between the chorion and the 
foetus through the umbilical vessels. 

6. An interspace between the outer layer of the ovum and the 
amnion, in which is contained the umbilical vesicle and allantois and 
the corps recticule of Velpeau. 

7. The outer layer of the ovum, along with the subzonal membrane, 
forming the chorion and foetal placenta. 

The amnion is the most internal of the two membranes surrounding 
the foetus ; its origin at an early period of foetal life has already been 
described. It is a perfectly smooth, transparent, but tough membrane, 
continuous with the integument of the foetus at the insertion of the 
umbilical cord, round which it forms a sheath. Soon after it is 
formed it becomes distended with a fluid, the liquor amnii, in which 
the foetus is suspended and floats. This fluid increases gradually in 
quantity, distending the amnion as it does so, until this is brought into 
close proximity to the inner surface of the chorion, from which it was 
at first separated by a considerable interspace. 

The internal surface of the amnion is smooth and glistening, and on 
microscopic examination it is found to consist of a layer of flattened 
cells, each containing a large nucleus. These rest on a stratum of 
fibrous tissue which gives to the membrane its toughness, and by which 
it is attached to a layer of gelatinous tissue which separates it from the 
inner surface of the chorion. This fibrous layer contains muscular 
fibres wdiich give to the amnion its contractility. It is entirely destitute 
of vessels, nerves, and lymphatics. The quantity of the liquor amnii 
varies much at different periods of pregnancy. In the early months it 
is relatively greater in amount than the foetus, which it outweighs. As 



CONCEPTION AND GENERATION, 

Fig. 59. 



Ill 




^>^^.<:^ 



Five Diagrammatic Figures illustrating the Formation of the Fcetal Membranes of a Mammal. 

(After Kolliker.) 

In 1, 2, 3, 4, the embryo is reprosoiited in longitndinal section. 

1. Ovum with zona pelhicida, bhistodermic vesicle, and embryonic area. 

2. Ovum with commencing; formation of umbilical vesicle and amnion. 

3. Ovum with amnion about to cease, and conimenciug; allantois. 

4. Ovum with villous subzonal nu'nd)rano, lar,i;cr allantois, and mouth and amis. 

5. Ovum in which the mesoblast of tlie allantuis lias extended round the inner sui-face of the subzonal mem- 

brane and united with it to form the cliorion. The cavity of the allantois is aborted. This figure is a 
diagram of an early human ovum. 
d. zonaradiata; (i/ ancl vSi-. i)rocesses of zona; f^h. subzonal membmne, outer fold of amnion, false amnion; 
ch. chorion; ch.z. chorionic villi ; nm. amnion; l:s. head-fold of amnion ; s.--. tail-fold of amnion : <i. 
epiblast of embryo; a', epiblast of non-embryonic part of the blastodermic vesicle: tit. embryonic 
mesoblast; )iif. non-embryonic mesoblast; dj. area vasculosa ; st. sin\is terniinalis; dd. embryonic 
hypoblast; i. non-embryonic hyimblast ; /,//. cavity of blastodermic vesicle, the greater part of which 
beconu>s the cavity of umbilicai vesicle da.; d(j. stalk of un\bilical vesicle; <d. allantois; t\ embryo; 
r. space between chorion and amnion containing albuminous tluid; vl. ventml body-wall; hh. perioaiilial 
cavity. 

prco;nancy advances the weio-ht of the ftvtiis beeonies fmir or five times 
gTcater than that of the H(|iior amiiii, aUhouoh the aetual t]iiantitv of 
fiuid increases duriiio; the whoU^ period of gestation. The amount o\^ 
fluid varies much in dilferent pregnaneies. Sometimes there is eompar- 



112 PREGNANCY. 

atively little, while at others the quantity is immense, reaching several 
pounds in weight, greatly distending the uterus, and thus, it may be, 
producing difficulty in labor. 

At first the liquid is clear and limpid. As pregnancy advances it 
becomes more turbid and dense, from the admixture of epithelial debris 
derived from the cutaneous surface of the foetus. In some cases, with- 
out actual disease, it may be dark green in color and thick and tenacious 
in consistency. It has a peculiar heavy odor, and it consists chemically 
of water containing albumen, some urea, and various salts, principally 
phosphates and chlorides. 

The source of the liquor amnii has been much disputed. Some 
maintain that it is derived chiefly from the foetus — a view sufficiently 
disproved by the fact that the liquor amnii continues to increase in 
amount after the death of the foetus. Burdach believed that it is 
secreted by the internal surface of the uterus, and arrives in the cavitv 
of the amnion by transudation through the membrane. Priestley — and 
this seems the most probable hypothesis — thinks that it is secreted by 
the epithelial cells lining the membrane, which become distended with 
fluid, burst, and pour their contents into the amniotic cavity. Gusserow, 
whose view is adopted by Spiegelberg, maintains that in the latter 
months of pregnancy the quantity of the liquor amnii is largely in- 
creased by the foetal urine which is passed into the amniotic sac. (See 
p. 135.) ^ 

The most obvious use of the liquor amnii is to afford a fluid medium 
in which the foetus floats, and so is protected from the shocks and jars 
to which it would otherwise be subjected, and from undue pressure upon 
the uterine walls. By distending the uterus it saves it from injury, 
which the movements of the foetus might otherwise inflict, and the 
foetus is thus also enabled to change its position freely. The facility 
with which version by external manipulation can be effected depends 
entirely on the mobility of the foetus in the fluid which surrounds it. 
Some have also supposed that it prevents the foetus in the early months 
of pregnancy from forming adhesions to the amnion. In labor it is of 
great service by lubricating the passages, but chiefly by forming, with 
the membranes, a fluid wedge which dilates the circle of the os 
uteri. 

In a few rare cases there is a certain amount of limpid fluid be- 
tween the chorion and the amnion, separating the two membranes. 
This is apparently only a more than usually fluid condition of the gelat- 
inous tissue which naturally exists between the chorion and amnion. 
Occasionally, after the bag of membranes is felt in labor the chorion 
alone ruptures, and the spurious liquor amnii is discharged, giving the 
attendant the impression that the membranes have been ruptured. 

The chorion is the more external of the truly foetal membranes, 
although external to it is the decidua, having a strictly maternal origin. 
It is a perfectly closed sac, its external surface, in contact with the 
decidua, being rough and shaggy from the development of villi (Fig. 
56), its internal smooth and shining. As the ovum passes along the 
Fallopian tube it receives, as we have seen, an albuminous coating, and 
this, with the zona pellucida, is developed into a temporary structure, the 



CONCEPTION AND GENERATION. 113 

-primitive chorion. This primitive chorion as the amnion develops is 
reinforced by the layer of epiblast covering the umbilical vesicle ex- 
ternally, which separates it from the subjacent mesoblast and hypoblast, 
and, together with the epiblastic layer of the false amni(jn, with which 
it is continuous, passes to the primitive chorion, either combining with 
this or by pressure causing its absorption and disappearance. 

The membrane thus formed is called by Turner the subzonal mem- 
brane, and by Von Baer the serous envelope. From it are developed 
villi of cellular structure, which at first extend as a ring round the 
ovum, but eventually cover the whole of its surface. These villi 
are finger-like projections from the surface of the ovum which are re- 
ceived into corresponding depressions in the decidua, with which 
they soon become so firmly united that they cannot be separated with- 
out laceration. 

As the allantois develops, its mesoblastic layer grows into the space 
between the embryo and subzonal membrane, and in the human subject 
spreads over the whole of its inner surface, combining with it to form 
a new membrane, the true or complete chorion. Each villus now 
receives a separate artery and vein, the former having a branch to each 
of the subdivisions into which the villus divides. These vessels are 
encased in a fine connective-tissue sheath from the allantois, which enters 
the villus along with them and forms a lining to it, described by 
some as the endochorion, the external epithelial membrane of the villus, 
derived from the epiblast layer of the blastodermic membrane, being 
called the exoGhorion. The artery and vein lie side by side in the 
centre of the villus, and anastomose at its extremity, each villus thus 
having a separate circulation. 

As soon as the union of the allantois with the chorion has been 
effected the villi grow very rapidly, give off branches, which, in their 
turn, give off secondary branches, and so form root-like processes of 
great complexity. In the early, months of gestation they exist equally 
over the whole surface of the ovum. As pregnancy advances, however, 
those which are in contact with the decidua reflexa shrivel up, and by 
the end of the second month cease to be vascular, being no longer 
required for the nutrition of the ovum. The chorion and decidua thus 
come into close contact, being united together by fibrous shreds, which 
on microscopic examination are found to consist of atrophied villi. The 
union between the chorion and the decidua reflexa as pregnancy 
advances becomes so complete that their line of junction cannot be 
ascertained, and they together with the decidua vera form one mem- 
brane, which on its inner surface is only separated from the anniion, 
which has spread over it, by a fine layer of gelatinous tissue. The 
portion of the chorion which is in relationship to the decidua rotioxa 
is known as the chorion hevo, whilst that in contact with the decidua 
serotina receives the name of the chorion frondosum; and in this 
portion t\\Q villi, instead of dwindling away, increase greatly in size» 
and eventually develop into the organ by which the ftvtus is ntnn'isluHl 
— the placenta. 

Form of the Placenta. — This important organ serves the pur- 
pose of supplying nutriment to, and aerating the bkHKi oi\ the ftvtus, 



114 PREGNANCY. 

and on its integrity the existence of tlie foetus depends. It is met 
with in all mammals, but is very different in form and arrangement 
in different classes. Thus, in the sow, mare, and in the cetacea it is 
diffused over the whole interior of the uterus; in the ruminants it 
is divided into a number of separate small masses, scattered here 
and there over the entire uterine walls ; while in the carnivora and 
elephant it forms a zone or belt round the uterine cavity. In the 
human race, as well as in rodentia, insectivora, etc., the placenta is in 
the form of a circular mass, attached generally to some part of the 
uterus near the orifices of one Fallopian tube ; but it may be sit- 
uated anywhere in the uterine cavity, even over the internal os uteri. 
The form of placentation in man and the apes is known as the meta- 
discoidal, whilst in rodentia and insectivora the placentation is discoidal. 
The metadiscoidal placentation is placed ventrally with regard to the 
embryo, and the allantois extends over the whole of the subzonal mem- 
brane, whilst in the discoidal variety the placenta is placed dorsally, 
and the allantois only extends over a portion of the subzonal mem- 
brane, to the remainder of which the yelk-sac is applied. As it is 
expelled after delivery with the foetal membranes attached to it, and 
as the aperture in these corresponds to the os uteri, we can generally 
determine pretty accurately the situation in which the placenta was 
placed by examining them after expulsion. The maternal surface of 
the placenta is somewhat convex, the foetal concave. Its size varies 
greatly in different cases, and it is usually largest when the child is 
big, but not necessarily so. Its average diameter is from 6 to 8 
inches, its weight from 18 to 24 ounces, but in exceptional cases it 
has been found to weigh several pounds. Abnormalities of form are 
not very rare. Thus, the placenta has been found to be divided into 
distinct parts, a form said by Professor Turner to be normal in cer- 
tain genera of monkeys, or smaller supplementary placentse {placentce 
succenturice) may exist round a central mass. These variations of shape 
are only of importance in consequence of a risk of part of the detached 
placenta being left in the uterus after delivery and giving rise to sep- 
ticaemia or secondary hemorrhage. 

The foetal membranes cover the whole foetal surface of the pla- 
centa, being reflected from its edges so as to line the uterine cavity, 
and being expelled with it after delivery. They also leave it at the 
insertion of the cord, to which they form a sheath. The cord is gen- 
erally attached near the centre of the placenta, and from its insertion 
the umbilical vessels may be seen dividing and radiating over the 
whole foetal surface. 

The maternal surface is rough and divided by numerous sulci, 
which are best seen if the placenta is rendered convex, so as to resem- 
ble its condition when attached to the uterus. A careful examination 
shows that a delicate membrane covers the entire maternal surface, 
unites the sulci together, and dips down between them. This is, in 
fact, the cellular layer of the decidua serotina, which is separated and 
expelled with the placenta, the deeper layer remaining attached to the 
uterus. Numerous small openings may be seen on the surface, which 
are the apertures of the veins torn off from the uterus, as also those 



CONCEPTION ANT) GENERy\TTON. 



115 



of some arteries, which, after taking several sharp turns, open suddenly 
into the substance of the organ. 

As regards the minute structure of the placenta, it is certain that it 
consists essentially of two distinct portions — one foetal, consisting of 
the greatly hypertrophied chorion villi, with their contained vessels, 
which carry the foetal blood so as to bring it into intimate relation with 
the maternal blood, and thus admit of the necessary changes occurring 
in it connected with the nutrition of the foetus ; and the other maternat, 
formed out of the decidua serotina and the maternal blood-vessels. 
These two portions are in the human female so intimately blended as to 
form the single deciduous orphan which is thrown off after deliverv. 
These main facts are admitted by all, but considerable differences of 
opinion still exist among anatomists as to the precise arrangement 
of these parts. In the following sketch of the subject I shall describe 
the views most generally entertained, merely briefly indicating the 
points which are contested by various authorities. 

The foetal portion of the placenta consists essentially of the ulti- 
mate ramifications of the chorion villi, which may be seen on micro- 
scopic examination in the form of club-shaped digitations, which are 
given off at every possible angle from the stem of a parent trunk, 




Placontnl Villus, .<;roatly majiuitlod. (After Joulin.) 

1, 2. Placontal vessels forming teiiuinal loops. X Chorion tissue, forming oxtornul walls of villus 
4. Tissue surrounding vessels. 



just like the branches of ' a i)lant. Within the transparoiit walls ol' 
the villi the capillary tubes of the contained vessels nuw be seen l\i no- 
distended witji blood, and presenting an appearaiun^ not uulike loi^ps 



116 PBEGXAyCY. 

of small intestine. The capillaries are the terminal ramifications of 
the umbilical arteries and veins, which, after reaching the site of the 
placenta, divide and subdivide until they at last form an immense 
number of minute capillarv vessels, with their convexities looking 
toward the maternal portion of the placenta, each terminal loop being- 
contained in one of tlie digitations of the chorion villi. Each arte- 
rial twig is accompanied by a corresponding venous branch, which 
unites Avith it to form the terminal arch or loop (Fig. 60). The foetal 
blood is carried through these arterial twigs to the villi, where it 
comes into intimate contact with the maternal blood, in consequence 
of the anatomical arrangements presently to be described ; but the two 
do not directly mix, as the older physiologists believed, for none of 
the maternal blood escapes when the umbilical cord is cut, nor can 
the minutest injections through the foetal vessels be made to pass into 
the maternal vascular system, or vice versa. In addition to the looped 
terminations of the umbilical vessels, Farre and Schroeder van der 
Kolk have described another set of capillary vessels in connection 
with each villus (Fig. 61). This consists of a very fine network cover- 

Fig. 61. 




a. Terminal villus of foetal tuft, minutelv injected, h. Its nucleated non-vascular sheath. 

(After Farre.) 

ing each villus, and very different in appearance from the convolu- 
ted vessels lying in its interior, which are the only ones which have 
been usually described. Dr. Farre believes that these vessels only 
exist in the early months of pregnancy, and that they disappear as 
pregnancy advances. Priestley ' suggests that they may not be vessels 
at all, but lymphatics, which may possibly absorb nutrient material 
from tlie mother's blood and throw it into the foetal vascular system. 
The existence of lymphatics or nerves in the placenta, however, has 
never been demonstrated, and they are believed not to exist. 

As generally described, the maternal portion of the placenta consists 
of large cavities or of a single large cavity which contains the maternal 

^ TAe Gravid Uterus, p. 52. 



CONCEPTION AND GENERATION 



117 



bloody and into whicli the villi of the chorion penetrate (Fig. 62;. Into 
this maternal part of the vi.scus the curling arteries of the uterus pour 
their bloody which is collected from it by the uterine sinuses. The 



Fig. 62. 




Diagram representing a Vertical Section of the Placenta. (After Dalton.) 
a, a. Chorion, h, h. Decidua. c, c, c, c. Orifices of uterine sinuses. 



villi of the chorion, therefore, are suspended in a sac filled with mater- 
nal blood, which penetrates freely between them, and with Avhich they 
are brought into very intimate contact. Dr. John Reid believed that 
only the delicate internal lining of the maternal vessels entered the 

Fig. 63. 



Fig. 64. 




Diagram illustrating the ^lode in which a 
I'lacental Villus derives a covering from 
the Vascular System of the I\iother. 
(After Priestley.) 

<i. Villus having throo tonninal (limitations pro- 
jecting into b. Cavity of the niotlnM-'s vessel, 
c. Dotted lines rei>res(>nting coat of vessel. 




The Exlremitv of a Placental Villus. 
1 After Goodsir.) 

o. External lueiubnine of villus (the lining mem- 
brane of vascular svstem of WeberV 
h. External cells .^f villus derived from deci.hia. 

c. c. Nuclei of ditto. 

d. The sjiace between the uuiteriial and fivtal 

portions o'( villus. 

e. Its internal nienvbniue. 
/. Us internal cells. 

</. The loop of umbilical vessels. 



substance of the placenta t(> \'oy\\\ the s:u' just spoluMi of. liit(^ this ilic 
villi project, ]>ushing before tluMU th<^ uuMubrniu^ loniiini:- the liniiiiiii:- 
wall of the ])lacental sinuses, each o)^ them in this way receiving an 



118 FBEGXAXCY. 

investment, just as the fincrers of a liand are covered bv a glove (Fig. 

Schroeder van der Kolk and Goodsir (Fig. 64) were of opinion that 
not only Avere the maternal blood-vessels continued into the substance 
of the placenta, but also the processes of the decidua which accompanied 
the vessels and wei-e prolonged over each villus, so as to separate it 
from the limiting membrane of the maternal sinuses. Each villus 
would thus be covered bv two layers of fine tissue — one from the inter- 
nal lining membrane of the maternal blood-vessels, the other from the 
epithelial cells of the decidua. 

Turner, whose valuable researches on the comparative anatomy of the 
placenta have thrown much light on its structure, points out that the 
placentae of all animals are formed on the same fundamental type,^ in 
which the fcetal portion consists of a smooth, plane-surfaced vascular 
membrane covered with pavement epithelium, which is brought into 
contact with the maternal portion, consisting of a smooth, plane-surfaced 
vascular membrane covered with columnar epithelium. The foetal 
capillaries are separated from the maternal capillaries only by two 
opposed layers of epithelium. In various animals the placentae are 
more or less specialized from the generalized form, in some to a much 
greater extent than others. In the human placenta the maternal vessels 
have lost their normal cylindrical form, and are dilated into a system of 
freely intercommunicating placental sinuses, which are, in fact, mater- 
nal capillaries enormously enlarged, with their walls so expanded and 
thinned out that they cannot be recognized as a distinct layer limiting 
the sinus. Each foetal chorion villus projecting into these sinuses is 
covered w^ith a layer of cells distinct from those of the epithelial layer 
of the villus, and readily stripped from it. These are maternal in their 
origiiij and. are derived from the decidua, which sends prolongations of 
its tissue into the placenta. These cells, he believes, form a secreting 
epithelium which separates from the maternal blood a secretion for the 
nourishment of the foetus, which is, in its turn, absorbed by the villi of 
the chorion. 

A view not very dissimilar to this has been advanced by Professor 
Ercolani of Bologna, who maintains that the maternal portion of the 
placenta is a new formation, strictly glandular and not vascular in its 
structure. It is formed, he thinks, by the submucous connective tissue 
of the decidua serotina, and it dips down into the placenta and forms a 
sheath to each of the chorion villi, which it separates from the maternal 
blood. This new glandular structure he describes as secreting a fluid, 
termed the ^' uterine milk," which is absorbed by the villi of the 
chorion, just as the mother's milk is absorbed by the villi of the intes- 
tines ; and it is with this fluid alone that the chorion villi are in direct 
contact. The sheath thus formed to each villus is doubtless analogous 
to the layer of cells which Goodsir described as encasing each villus, but 
is attributed to a new" structure formed after conception. 

The existence of the maternal-sinus system in the placenta is 
altogether denied by anatomists of eminence whose views are worthy of 

^ Introduction to Human Anatomy, Part 2, and Journ. of Anat. and Physiology, 1877, 
vol. xi. p. 33. 



CONCEPTION AND GENERATION. 119 

careful consideration. Prominent amongst these is Braxton Hicks/ 
who has written an elaborate paper on the subject. He holds that there 
is no evidence to prove that the maternal blood is poured out into a 
cavity in which the chorion villi float, and he Vjelieves that the curling 
arteries, instead of entering the so-called maternal portion of the pla- 
centa, terminate in the decidua serotina. The hypertrophied chorion 
villi at the site of the placenta are firmly attached to the decidual sur- 
face, into which their tips are imbedded. The line of junction l^etween 
the decidua reflexa and serotina forms a circumferential margin to, and 
limits, the placenta. The arrangement of the foetal portion of the pla- 
centa on this view is very similar to that generally described, but the 
villi are not surrounded by maternal blood at all, and nothing exists 
between them unless it be a sniall quantity of serous fluid. The change 
in the foetal blood is effected by endosmosis, and Hicks suggests that 
the follicles of the decidua may secrete a fluid which is poured into the 
intervillous spaces for absorption by the villi. 

Functions of the Placenta. — It will thus be seen that anatomists 
of repute are still undecided as to important points in the minute 
anatomy of the placenta, which further investigation will doubtless 
clear up. The main functions of the organ are, however, sufficiently 
clear. During the entire period of its existence it fills the important 
office of both stomach and lungs to the foetus. Whatever view of the 
arrangement of the maternal blood-vessels be taken, it is certain that the 
foetal blood is propelled by the pulsations of the foetal heart into the 
numberless villi of the chorion, where it is brought into very intimate 
relation with the mother's blood, gives off its carbonic acid, absorbs 
oxygen, and passes back to the foetus, through the umbilical vein, in a 
fit state for circulation. The mode of respiration, therefore, in the 
foetus is analogous to that in fishes, the chorion villi representing the 
gills, the maternal blood the water in which they float. Nutrition is 
also effected in the organ, and by absorption through the chorion villi 
the pabulum for the nourishment of the foetus is taken up. It also 
probably serves as an emunctory for the products of excretion in the 
foetus. Picard found that the blood in the placenta contained an appre- 
ciably larger cpiantity of urea than that in other i)arts of the body, this 
urea probably being derived from the f(ctus. Claude Bernard also 
attributed to it a glycogenic function,^ sup]K~)sing it to take the place o^ 
the fcctal liver until that organ was sufficiently developed. 

Finally, we find that the temporary character of the placenta is indi- 
cated by certain degenerative changes which take place in it i)revious 
to expulsion. These consist chiefly in the deposit of calcareous patches 
on its uterine surface, and in fatty degeneration of the villi and yy( the 
decidual layer between the placenta and the uteru^;. It' this degene- 
ration be carried to excess, as is not unfrequently the case, the fictus 
may perish from w'ant of a sufficient number of healthy villi through 
which its respiration and nutrition may be efleeted. 

The umbilical cord is the channel of communication between the 
f(ctus and placenta, IxMng "attached to the former at the umbilicus, to 
the latter generally near its centre, but sometimes, as in the battledore 

^ Ohsi. Tnots., 1873, vol. xiv. p. Mil » AcuiLdc.< S'iouy.<, April. ISVJ. 



120 PREGNANCY. 

placenta, at its edge. It varies much in length, measuring on an aver- 
age from 18 to 24 inches, but in exceptional cases being found as long 
as 50 or 60^ and as short as 5 or 6, inches. 

AVhen fully formed it consists of an external membranous layer 
formed of the amnion, two umbilical arteries, one umbilical vein, and 
a considerable quantity of a transparent gelatinous substance surround- 
ing the vessels called Wharton's jelly, which is contained in a fine 
network of fibres, and is formed from the somatopleural layer of the 
mesoblast in the cord. At an early period of pregnancy, in addition to 
these structures, the cord contains the pedicle of the umbilical vesicle, 
with the omphalo-mesenteric vessels ramifying on it, and two umbilical 
veins, one of which soon atrophies and disappears. No nerves or 
lymphatics have been satisfactorily demonstrated in the cord, although 
such have been described as existing. The vessels of the cord are at 
first straight in their course, but shortly they become greatly twisted, 
the arteries being external to the vein, and in nine cases out of ten the 
twist is from left to right. A^arious explanations have been given of 
this peculiarity, none of them entirely satisfactory. Tyler Smith 
attributed it to the movements of the foetus twisting the cord, its 
attachment to the placenta being a fixed point ; this would not, how- 
ever, account for the frequency with which the spiral turns occur in 
one direction. Mr. John Simpson attributed it to the greater pressure 
of the blood through the right hypogastric artery, on account of that 
vessel having a more direct relation to the aorta than the left. The 
umbilical arteries give off no branches, and the vein contains no valves, 
nor can any vasa vasorum be detected in their coats after they have left 
the umbilicus. The umbilical arteries increase in size after they leave 
the cord to divide on the surface of the placenta. This is the only ex- 
ample in the body in which arteries are larger near their terminations 
than their origin, and the object of this arrangement is probably to 
effect a retardation of the current of the blood distributed to the 
placenta. The tortuous course of the vein probably compensates for 
the absence of valves, and moderates the flow of blood through it. 
Distinct knots are not unfrequently observed in the cord, but they 
rarely have the effect of obstructing the circulation through it. They 
no doubt form when the foetus is very small. They may sometimes 
also be produced in labor by the child being propelled through a coil 
of the cord lying circularly round the os uteri. The so-called false 
knots are merely accidental nodosities due to local enlargements of the 
vessels. 



THE ANATOMY AND PHYSIOLOGY OF THE FCETUS. 121 



CHAPTER II. 

THE ANATOMY AND PHYSIOLOGY OF THE F(ETUS. 

It is obviously impossible to attempt anything like a full account of 
the development of the various foetal structures or of their growth 
during intra-uterine life. To do so would lead us far beyond the 
scope of this work, and would involve a study of com2)lex details only 
suitable in a treatise on embryology. It is of importance, however, 
that the practitioner should have it in his power to determine approxi- 
mately the age of the foetus in abortions or premature labors, and for 
this purpose it is necessary to describe briefly the appearance of the 
foetus at various stages of its growth. 

1st month. — The foetus in the first month of gestation is a minute 
gelatinous and semi-transparent mass, of a grayish color, in which no 
definite structure can be made out and in which no head or extremities 
<3an be seen. It is rarely to be detected in abortions, being lost in sur- 
rounding blood-clots. In the few examples which have been carefully 
examined it did not measure more than a line in length. It is, how- 
ever, already surrounded by the amnion, and the pedicle of the umbili- 
cal vesicle can be traced into the unclosed abdominal cavity. 

2d month. — -The embryo becomes more distinctly apparent, and is 
curved on itself, weighing about 62 grains and measuring 6 to 8 
lines in length. The head and extremities are distinctly visible — the 
latter in the form of rudimentary projections from the body. The eyes 
are to be seen as small black spots on the side of the head. The spinal 
column is divided into separate vertebme. The independent circulatory 
system of the foetus is now beginning to form, the heart consisting of 
only one ventricle and one auricle, from the former of which both the 
aorta and pulmonary arteries arise. On either side of the vertebral 
column, reaching from the heart to the pelvis, are two large glandular 
structures, the corpora Woljfiana, which consist of a series of convolu- 
ted tubes opening into an excretory duct running along their external 
borders and connected below with the common cloaca of the genito- 
urinary and digestive tracts. They seem to act as secreting glands, 
and fulfil the functions of the kidneys before they are fornuxl. 
Toward the end of the second month they atrophy and disap- 
pear, and the only trace of them in the fa^tus at term is to be 
found in the parovarium lying between the folds of the broad 
ligaments. At this stage of develo])ment there are met with in 
the human embryo, as in that of all nuininmls, tour transvei-se 
fissures opening into the pharynx, which are analogous lo tlie per- 
manent branchiae of fishes. Their vascular supply is also similar, as 
the aorta at this time gives otV tour branches on each side, eai*h oi^ which 
forms a branchial arch, and these afterward imitc to tbnn the descend- 



122 PREGNANCY. 

ing aorta. By the end of the sixth week these, as well as the transverse 
fissures to which they are distributed, disappear. By the end of the 
second month the kidneys and suprarenal capsules are forming, and the 
single ventricle is divided into two by the growth of the interventricu- 
lar septum. The umbilical cord is quite straight, and is inserted into 
the lower part of the abdomen. Centres of ossification are showing 
themselves in the inferior maxillary bones o-n the clavicle. 

3d month. — The embryo weighs from 70 to 300 grains and measures 
from 2J to 3J inches in length. The forearm is well formed, and the 
first traces of the fingers can be made out. The head is large in pro- 
portion to the rest of the body, and the eyes are prominent. The um- 
bilical vesicle and allantois have disappeared, and the alimentary canal 
is now situated entirely within the abdominal cavity ; the greater por- 
tion of the chorion villi have atrophied, and the placenta is distinctly 
formed. 

4th month. — The weight is from 4 to 6 ounces and the length about 
6 inches. The convolutions of the brain are beginning to develop. 
The sex of the child can now be ascertained on inspection. Hairs 
begin to be formed on the head. The muscles are sufficiently formed 
to produce distinct movements of the limbs. Ossification is extending, 
and can be traced in the occipital and frontal bones and in the mastoid 
processes. The sexual organs are differentiated. 

oth month. — Weight, about 10 ounces ; length, 9 or 10 inches. Hair 
is observed covering the head, which forms about one-third of the 
length of the whole foetus. The nails are beginning to form, and ossi- 
fication has commenced in the ischium. 

6th month. — Weight, about 1 pound ; length, 11 to 12 J inches. The 
hair is darker. The eyelids are closed, and the meinbrana pupillaris 
exists ; eyelashes have now been formed. Some fat is deposited under 
the skin. The testicles are still in the abdominal cavity. The clitoris is 
prominent. The pubic bones have begun to ossify. 

7th month. — Weight, from 3 to 4 pounds; length, 13 to 15 inches. 
The skin is covered with unctuous, sebaceous matter, and there is a 
more considerable deposit of subcutaneous fat. The eyelids are open. 
The testicles have descended into the scrotum. 

8th month. — Weight, from 4 to 5 pounds; length, 16 to 18 inches, 
and the foetus seems now to grow in thickness rather than in length. 
The nails are completely developed. The membrana pupillaris has 
disappeared. 

At the completion of pregnancy the foetus weighs on an average 
6J pounds, and measures about 20 inches in length. These averages 
are, however, liable to great variation. Remarkable histories are given 
by many writers of foetuses of extraordinary weight, wliich have been 
probably greatly exaggerated. Out of 3000 children delivered under 
the care of Gazeaux at various charities, one only weighed 10 pounds. 
There are, however, several carefully recorded instances of weight far 
exceeding this, ]~>ut they are undoubtedly much more uncommon than 
is generally supposed. Dr. Ramsbottom mentions a foetus weighing 
16 J pounds ; Cazeaux tells us of one which he delivered by turning 
which weighed 18 pounds and measured 2 feet 1 J inches ; and the 



THE ANATOMY AND PHYSIOLOGY OF THE FfETUS. 123 

birth of one weighing 21 pounds has been recently recorded.^ Such 
overgrown children are almost invariably stillborn.^ 

The average size of male children at birth, as in after life, is some- 
what greater than that of female. Thus Simpson^ found that out 
of 100 cases the male children averaged 10 ounces more in weight 
than the female, and half an inch more in length. 

[Some mothers of average size invariably bring forth very small 
children, never having one near an average weight. Such was the case 
with a lady under my care, whose heaviest male infant, now a vigorous 
boy of twelve years, weighed 5 J pounds. A female child, now a young 
lady, weighed 3J pounds ; and another of the same sex, that died at 
eight months, weighed only 2f pounds. It grew plump, but its lower 
extremities were deficient in muscular energy. The father of these 
children is of average height and weight. — Ed.] 

A newborn child at term is generally covered to a greater or less 
extent with a greasy, unctuous material, the vernix caseosa, which is 
formed of epithelial scales and the secretion of the sebaceous glands, 
and which is said to be of use in labor by lubricating the surface 
of the child. The head is generally covered with long dark hair, 
which frequently falls off or changes in color shortly after birth. Dr. 
Wiltshire* has called attention to an old observation, that the eyes 
of all newborn children are of a peculiar dark steel-gray color, and 
that they do not acquire their permanent tint until some time after 
birth. The umbilical cord is generally inserted below- the centre of 
the body. 

The most important part of the foetus from an obstetrical point 
of view is the head, which requires a separate study, as it is the usual 
presenting part, and the facility of the labor depends on its accurate 
adaptation to the maternal passages. 

Anatomy of the Fcetal Head. — The chief anatomical peculiarity 
of interest in the head of the foetus at term is that the bones of 
the skull, especially of its vertex — which, in the vast majority of cases, 
has to pass first through the pelvis — are not firmly ossified as in adult 
life, but are joined loosely together l)y membrane or cartilage. The 
result of this is that the skull is capable of being moulded and altered 
in form to a very considerable extent by the ])ressure to which it is 
subjected, and thus its passage through the pelvis is very greatly facili- 
tated. This, however, is chiefly the case with the cranium proper, 
the bones of the face and of the base of the skull being more firndv 
united. By this means the delicate structures at the bas(» of the brain 
are protected from pressure, while the change of form whicli the skull 

J Brit. Med. Joum.,Feh. 1, 1879. 

■^ Probably the laroest fcvtus on record was tliat of ^Irs. C^iptain I'ates, the Nova 
Scotia giantess, a woman of 7 feet 9 inches, whose husbantl is also o\ gi^aniie build, 
reaching 7 feet 7 inches in lieight. This ehild, Inn-n in Ohio, wns their seit^ul, 
and was lost in its birth, as no forceps eould be }>rcH'ured o\' sutUcient size to i;rasp the 
head. The fa^tns weighed 23;| pounds, and was oO inches in length. Their tii-st intant 
weighed 18 pounds. We havt^ had children born in this city ^rhiladelphia"* at matu- 
rity and live that weighed but one pound. The well-remembereil "* Piueus babv " 
weighed a pouiul and an ounce. — Harris, note to od American edition. 

^Si'Urh'if ()l),'<(. Worh, p. [V27. * Lmurt, February 11, ISTl. 



124 



PREGNANCY. 



undergoes during labor implicates a portion of the skull where pres- 
sure on the cranial contents is least likely to be injurious. 

The divisions between the bones of the cranium are further of obstet- 
ric importance in enabling us to detect the precise position of the head 
during labor, and an accurate knowledge of them is therefore essen- 
tial to the obstetrician. 

We talk of them as sutures and fontanelles, the former being the 
lines of junction between the separate bones, which overlap each other 
to a greater or less extent during labor ; the latter membranous inter- 
spaces where the sutures join each other. 

The principal sutures are — 1st. The sagittal, which separates the two 
parietal bones, and extends longitudinally backward along the vertex 
of the head. 2d. The froyital , which is a continuation of the sagittal, 
and divides the two halves of the frontal bone, at this time separate 
from each other. 3d. The corona/, which separates the frontal from the 
parietal bones, and extends from the squamous portion of the temporal 
bone across the head to a corresponding point on the opposite side. 
And 4th, the lambdoidal, which receives its name from its resemblance 
to the Greek letter A, and separates the occipital from the parietal 
bones on either side. The fontanelles (Fig. 65) are the membranous 



Fig. 65. 



Fig. 




Anterior and Posterior Fontan- 
elles. 




Bi-parietal Diameter, Sagittal and 
Lambdoidal Sutures, with Poste- 
rior Fontanelle. 



interspaces where the sutures join — the anterior and larger being loz- 
enge-shaped, and formed by the junction of the frontal, sagittal, and 
two halves of the coronal sutures. It will be well to note that 
there are, therefore, four lines of sutures running into it, and four 
angles, of which the anterior, formed by the frontal suture, is most 
elongated and well marked. The posterior fontanelle (Fig. 66) is 
formed by the junction of the sagittal suture with the two legs of the 
lambdoidal. It is, therefore, triangular in shape, with three lines of 
suture entering it in three angles, and is much smaller than the anterior 
fontanelle, forming merely a depression into which the tip of the finger 
can be placed, while the latter is a hollow as big as a shilling or even 



THE ANATOMY AND PHYSIOLOGY OF THE F(ETUS. 125 



Fig. 67. 




larger. As it is the posterior fontanelle which is generally lowest, and 
the one most commonly felt during labor, it is important for the student 
to familiarize himself with it, and he should lose no opportunity of 
studying the sensations imparted to the finger by the sutures and fon- 
tanelles in the head of the child after birth. 

The Diameters of the Foetal Skull. — For the purpose of under- 
standing the mechanism of labor, we must study the measurements of 
the foetal head in relation to the cavity through which it has to pass. 
They are taken from corresponding points opposite to each other, and 
are known as the diameters of the skull (Fig. 67). Those of most 
importance are — 1st. The occipito- 
mentalis (o. m), from the occipital 
protuberance to the point of the 
chin, 5.25'' to 5.50''. 2d. The 
occipito-frontalis (o. r), from the 
occiput to the centre of the fore- 
head, 4.50" to 5". 3d. The suh- 
occipito-bregmatica (s. o. b), from a 
point midway between the occipital 
protuberance and the margin of the 
foramen magnum to the centre of 
the anterior fontanelle, 3.25". 4th. 
The cervico-bregmatica (c. b), from 
the anterior margin of the foramen 
magnum to the centre of the ante- 
rior fontanelle, 3.75". 5th. Trans- 
verse or bi-parietalis (bi-p), between 
the parietal protuberances, 3.75" to 
4". 6th. Bi-itemporalis (bi-t), between the ears, 3.50". 7th. Fronfo- 
mentalts (f. m), from the apex of the foi-ehead to the chin, 3.25". 

The length of these respective diameters, as given by different w^riters, 
differs considerably, a fact to be explained by the measurements having 
been taken at different times — by some just after birth, when the head 
was altered in shape by the moulding it had undergone ; by others 
when this had either been slight or after the head had recovered its 
normal shape. The above measurements may be taken as the average 
of those of the normally-shaped head, and it is to be noted that the first 
tAvo are more apt to be modified during labor. The amount of compres- 
sion and moulding to which the head may be subjected witlunit proving 
fatal to the fciotus is not certainly known, but it is doubtless verv ci>n- 
siderable. Some interesting examples of the extent to which the head 
may be altered in shape in difhcult labors have been given bv Barnes,* 
who has shown by tracings of the shape of the head taken ininiediately 
after delivery that in protracted labor the ■occi{>ito-mental [o. m") am 
occi pi to-frontal (o. f) diameters may be increased mow 
length, w^hile lateral compression may diminish the 
diameter to the same length as the interauricular. 
movable on the vertical column to the extent of a (piarter o\' a circle : 
and it seems probable that (he laxity oi' the ligaments admits with 
^ Olh^t. Trans., 18tU!. vol. vii. p. 171. 



1 & 2. Diameter occipito-frontalis (o. f). 
3 & 4. occipito-mentalis (o. m). 

5 & G. cervico-bregmatica (c. B). 

7 & 8. fronto-meiitalis (f. m). 



than an inch m 
lead is 



' hi-parieta 
The fcvtal 



126 PEEGyAXCY. 

irnpuDity a greater circular movement than would be possible in the 
adult. 

On taking the average of a large number of measurements, it is 
found that the heads of male children are larger and more firmly ossi- 
fied than those of females, the former averaging about half an inch more 
in circumference. Sir James Simpson attributed great importance to 
this fact, and believed that it was sufficient to account for the larger 
proportion of stillbirths in male than in female children, as well as for 
the greater difficulty of labor and the increased maternal mortality that 
are found to attend on male births. His well-known paper on this 
subject, which has given rise to much controversy, is full of the most 
elaborate details ; and so great did he believe the foetal influence to be 
that he calculated that between the years 1834 and 1837 there were lost 
in Great Britain, as a consequence of the slightly larger size of the male 
than of the female head at birth, about 50,000 lives, including those of 
about 46,000 or 47,000 infants, and of between 3000 and 4000 mothers 
who died in childbed.^ It is probable that race and other conditions, 
such as civilization and intellectual culture, have considerable influence 
on the size of the foetal skull, but we are not in possession of sufficiently 
accurate data to justify any very positive opinion on these points. 

In the very large majority of cases the foetus lies in idcro with head 
downward, and is so placed as to be adapted in the most convenient way 
to the cavity in which it is placed. The uterine cavity is most roomy 
at the fundus, and narrowest at the cervix, and the greatest bulk of the 
fcetus is at the breech, so that the largest part of the child usually lies 
in the part of the uterus best adapted to contain it. The various parts 
of the child's body are further so placed, in regard to each other, as to 
take up the least possible amount of space. (See frontispiece.) The 
body is bent so that the spine is cur^'ed with its convexity outward, this 
curvature existing from the earliest period of development ; the chin is 
flexed on the sternum ; the forearms are flexed on the arms, and lie 
close together on the front of the chest ; the legs are flexed on the thighs, 
and the thighs drawn up on the abdomen ; the feet are drawn up 
toward the legs ; the umbilical cord is generally placed out of reach of 
injurious pressure in the spaces between the arms and the thighs. 
Variations from this attitude, however, are not uncommon, and are not, 
as a rule, of much consequence. Although the cranial presentations are 
much the most common, averaging 86 out of every 100 cases, other 
presentations are by no means rare, the next most frequent being either 
that of the breech, in which the lonp^ diameter of the child lies in the 
long diameter of the uterine cavity, or some variety of transverse pres- 
entation, in which the long diameter of the foetus lies obliquely across the 
uterus, and no longer corresponds to its longitudinal axis. 

It was long believed that the head presentation was only assumed 
toward the end of pregnancy, when it was supposed to be produced by 
a sudden movement on the part of the fcetus, knoAvn as the cidbide. It 
is now wtII known that in the large majority of cases the head is lowest 
during all the latter part of pregnancy, although changes in position are 
more common than is generally believed to be the case, and presentation 

1 Selected Obst. Worh, p. 363, 



THE ANATOMY AND PHYSIOLOGY OF THE FCETUS. 



127 



of parts other than the head is much raore frequent in premature labor 
than in delivery at terra. In evidence of the last statement, Churchill 
says that in labor at the seventh month the head presents only 83 times 
out of 100 when the child is living, and that as many as 53 per cent, 
of the presentations are preternatural when the child is stillborn. The 
frequency with which the foetus changes its position before delivery has 
been made the subject of investigation by various German obstetricians, 
and the fact can be readily ascertained by examination. Valenta^ found 
that out of nearly 1000 cases, carefully and frequently examined by 
him, in 57.6 per cent, the presentation underwent no change in the 
latter months of pregnancy, but in the remaining 42.4 per cent, a 
change could be readily detected. These alterations were found to be 
most frequent in multiparse, and the tendency was for abnormal presenta- 
tions to alter into normal ones. Thus it was common for transverse pres.- 
entations to alter longitudinally, and but rare for breech presentations to 
change into head. The ease with which these changes are effected no 
doubt depends, in a considerable degree, on the laxity of the uterine 
parietes and on the greater quantity of amniotic fluid, by both of which 
the free mobility of the foetus is favored. 

The facility with which the position of the foetus in ufero can be 
ascertained by abdominal palpation has not been generally appreciated 
in obstetric works, and yet by a little practice it is easy to make it out. 
Much information of importance can be gained in this way, and it is 
quite possible, under favorable circumstances, to alter abnormal pres- 

FiG. 68. 




Mode of Ascertaining- the Position oftho FuMus by Palpiuion. 

entations before labor has begun. For the purpose oi' makino iliis 
examination the patient should lie at the edge of the bod, wiili her 
shoulders slightly raised and the abdomen uncovorcxl. The tirst obsor- 

^ Man., f. QehurL, ISiio, Bd. xxiv. 8. 17*2; and lStU>. Bd. xxviii. 8. otU : " Ciolnirts- 
hulUiche Studien." 



128 PREGNANCY. 

vatiou to make is to see if the loiigitudiDal axis of the uterine tumor 
corresponds Avith that of the mother's abdomen ; if it does, the presenta- 
tion must be either a head or a breech. By spreading the hands over 
the uterus (Fig. Q'S) a greater sense of resistance can be felt, in most 
cases, on one side than on the other, corresponding to the back of the 
child. By striking the tips of the fingers suddenly inward at the fundus, 
the hard breech can generally be made out, or the head still more easily 
if the breecli be downwarcl. AYhen the uterine myalls are unusually lax 
it is often possible to feel the limbs of the child. These observations 
can be generally corroborated by auscultation, for in head presentations 
the foetal heart can usually be heard below the umbilicus, and in breech 
cases above it. Transverse presentations can even more easily be made 
out by abdominal palpation. Here the long axis of the uterine tumor 
does not correspond with the long axis of the mother's abdomen, but 
lies obliquely across it. By palpation the rounded mass of the head can 
be easily felt in one of the mother's flanks, and the breech in the other, 
while the foetal heart is heard pulsating nearer to the side at which the 
head is detected. 

The reason why the head presents so frequently has been made the 
subject of much discussion. The oldest theory was, that the head lay 
over the os uteri as the result of gravitation, and the influence of gravity, 
although contested by many obstetricians, prominent among whom were 
Dubois and Simpson, has been insisted upon as the chief cause by 
others, Dr. Duncan being one of the most strenuous advocates of this 
view. The objections urged against the gravitation theory were drawn 
partly from the result of experiments, and partly from the frequency 
with which abnornal presentations occur in premature labors, when the 
action of gravity cannot be supposed to be suspended. The experi- 
ments made by Dubois went to show that when the foetus was 
suspended in water gravitation caused the shoulders, and not the 
head, to fall lowest. He therefore advanced the hypothesis that the 
position of the foetus was due to instinctive movements which it made 
to adapt itself to the most comfortable position in which it could lie. It 
need only be remarked that there is not the slightest evidence of the 
foetus possessing any such power. Simpson proposed a theory which was 
much more plausible. He assumed that the foetal position was due to 
reflex movements produced by physical irritations to which the cutane- 
ous surface of the foetus is subjected from changes of the mother's 
position, uterine contractions, and the like. The absence of these 
movements, in the case of the death of the foetus, would readily ex- 
plain the frequency of mal-presentations under such circumstances. 
The obvious objection to this theory, complete as it seems to be, is the 
absence of any proof that such constant extensive reflex movements 
really do occur in utero. Dr. Duncan has very conclusively disposed 
of the principal objections which have been raised against the influence 
of gravitation, and when an obvious explanation of so simple a kind 
exists it seems useless to seek farther for another. He has shown that 
Dubois' experiments did not accurately represent the state of the foetus 
in utero, and that during the greater part of the day, when the woman 
is upright or lying on her back, the foetus lies obliquely to the horizon 



TKE ANATOMY AND PHYSIOLOGY OF THE F(ETUS. 129 

at an angle of about 30°. The child thus lies, in the former case, on an 
inclined plane formed by the anterior uterine wall and by the abdomi- 
nal parietes ; in the latter, by the posterior uterine wall and the 
vertebral column. Down the inclined plane so formed the force of 




Diagram illustrating the Effect of Gravity on the Foetus. (After Duncan.) 

a, b, is parallel to the axis of the pregnant uterus and pelvic brim, c, d, e, is a perpendicular line, e, the 
centre of gravity of the foetus, d, the centre of flotation. 

gravity causes the foetus to slide, and it is only when the woman lies on 
her side that the foetus is placed horizontally, and is not subjected in the 
same degree to the action of gravity (Fig. 69). The frequency of mal- 
presentations in premature labors is explained by Dr. Duncan partly by 



Fig. 70. 




-jL..r: ^^^^ ^ ^ :^^ ]±. 

Illustrating the Greater Mobility of the Fa^us and the Larger Relative Amount of Liquor 
Amnii in Early Pregnancy. (After Duncan.) 



«, b. Axi8 of pregnant utonis. 



^. /(. A hori/vntal lino. 



the fact that the death of the child (which so fiV(|uontly pivcodos such 
cases) alters its centre of gmvity, and |)artly by the givator mobilitv of 
the child and the greater relative amount of liquor amnii (Fio-. 70). 
The influence of gravitation is probably greatly a^^sisted bv the contract 



130 PREGNANCY. 

tions of the uterus which are going on during the greater part of preg- 
nancy. The influence of tliese was pointed out by Dr. Tyler Smith, 
who distinctly showed that the contractions of the uterus preceding 
delivery exerted a moulding or adapting influence on the foetus and 
prevented undue alterations of its position. Dr. Hicks proved^ that 
these uterine contractions are of constant occurrence from the earliest 
period of pregnancy, and there can be little doubt that they must have 
an important influence on the body contained within the uterus. The 
whole subject has been recently considered by Pinard,^ who shows that 
many factors are in action to produce and maintain the usual position 
of the foetus in utero, which may be either of an active or a passive 
character : the former being chiefly the active movements of the foetus 
and the contractions of the uterus and the abdominal muscles ; the 
latter, the form of the uterus and the foetus, the slippery surface of the 
amnion, pressure of the amniotic fluid, etc. When any of these factors 
are at fault mal-presentation is apt to occur. 

The functions of the foetus are in the main the same, with differences 
depending on the situation in which it is placed, as those of the sepa- 
rate being. It breathes, it is nourished, it forms secretions, and its 
nervous system acts. The mode in which some of these functions are 
carried on in intra-uteriue life requires separate consideration. 

Nutrition. — During the early part of pregnancy, and before the 
formation of the umbilical vesicle and the allantois, it is certain that 
nutritive material must be supplied to the ovum by endosmosis through 
its external envelope. The precise source, however, from which this is 
obtained is not positively known. By some it is believed to be derived 
from the granulations of the discus ])roligerus which surround it as it 
escapes from the Graafian follicle, and subsequently from the layer of 
albuminous matter which surrounds the ovum before it reaches the 
uterus ; while others think it probable that it may come from a special 
liquid secreted by the interior of the Fallopian tube as the ovum 
passes along it. As soon as the ovum has reached the uterus there is 
every reason to believe that the umbilical vesicle is the chief source of 
nourishment to the embryo through the channel of the omphalo-meseu- 
teric vessels, which convey matters absorbed from the interior of the 
vesicle to the intestinal canal of the foetus. At this time the exterior 
of the ovum is covered by the numerous fine villosities of the primi- 
tive chorion, which are imbedded in the mucous membrane of the 
uterus ; and it is thought that they may absorb materials from the 
maternal system, which may be either directly absorbed by the embryo 
or which may serve the purpose of replacing the nutritive matter which 
has been removed from the umbilical vesicle by the omphalo-mesenteric 
vessels. This point it is of course impossible to decide. Joulin, how- 
ever, thinks that these villi probably have no direct influence on the 
nourishment of the foetus, which is at this time solely effected by the 
umbilical vesicle, but that they absorb fluid from the maternal system, 
which passes through the amnion and forms the liquor amnii. As soon 
as the allantois is developed, vascular communication between the 
foetus and the maternal structures is established, and the temporary 
^ Obst. Trans., 1872, vol. xiii. p. 216. Annul de Gyn., 1878, torn. ix. p. 321. 



THE ANATOMY AND PHYSIOLOGY OF THE FCETUS. 131 

function of the umbilical vesicle is over; that structure, therefore, 
rapidly atrophies and disappears, and the nutrition of the futus is now 
solely carried on by means of the chorion villi, lined as they now are 
by the vascular endochorion, and chiefly by those which go to form the 
substance of the placenta. 

This statement is opposed to the views of many ])hysiologists, who 
believe that a certain amount of nutritive material is conveyed to the 
foetus through the channel of the liquor amnii, itself derived from the 
maternal system, which is supposed either to be absorbed through the 
cutaneous surface of the fcjetus or carried to the intestinal canal by 
deglutition. The reasons for assigning to the liquor amnii a nutri- 
tive function are, however, so slight that it is difficult to believe tliat it 
has any appreciable action in this way. They are based on some 
questionable observations, such as those of Weydlich, who kept a 
calf alive for fifteen days by feeding it solely on liquor amnii; and the 
experiments of Burdach, who found the cutaneous lymphatics engorged 
in a foetus removed from the amniotic cavity, while those of the intes- 
tine were empty. The deglutition of the liquor amnii for the pur[)oses 
of nutrition have been assumed from its occasional detection in the 
stomach of the foetus, the presence of which may, however, be readily 
explained by spasmodic efforts at respiration which the foetus undoubt- 
edly often makes before birth, esi)ecially when the placental circulation 
is in any way interfered with, and during which a certain quantity of 
fluid would necessarily be swallowed. The quantity of nutritive 
material, however, in tlie liquor amnii is so small — not more than 6 
to 9 parts of albuiuen in 1000 — that it is impossible to conceive how it 
could have any appreciable influence in nutrition, even if its absorption 
either by the skin or stomach were susceptible of proof. 

That the nutrition of the foetus is effected through the plncenta is 
proved by the common observation that whenever the placental circula- 
tion is arrested, as by disease of its structure, the foetus atrophies and 
dies. The precise mode, however, in which nutritive materials are 
absorbed from the maternal blood is still a matter of doubt, and must 
remain so until the mooted points as to the minute anatomy of the pla- 
centa are settled. The various theories entertained on this subject by 
the upholders of the Hunterian doctrine of placental anatomv, and by 
those who deny the existence of a sinus system, iiave already been 
referred to in the chapter on the Anatomy of the Placenta, to which the 
reader is referred (pp. 114-120). 

Respiration. — One of the chief functions of the }>lacenta, besides 
that of nutrition, is the su})ply of oxygenated blood to the fcvtus. That 
this is essential to the vitality of the fbtus, and that the placenta is the 
site of oxygenation, is shown by the fact that whenevin- the placenta is 
separated, or the access of the foetal blood to it arrested by (.'ompression 
of the cord, instinctive attempts at inspiration are made, and if aerial 
respiration cannot be [)erfbrnuHl the fivtus is expelled asphyxiatixh 
Like the other functions of (he tortus during imra-uterine life, that o^ 
respiration has Invn mad(» the subjiH't of numerous more or less inge- 
nious hypotheses. Thus, many \\:\\c believed that the t\vtus absorlunl 
gaseous material from the liipior amnii, which served the purpose o^ 



132 PREG^sAXCY. 

oxygenating its blood — St. Hilaire thinking that this was eifected by 
minute openings in its skin, Beclard and others through the bronchi, to 
which they believed the liquor amnii gained access. Independently of 
the entire want of evidence of the absorption of gaseous materials by 
these channels, the theory is disproved by the fact that the liquor amnii 
contains no air which is capable of respiration. Serres attributed a sim- 
ilar function to some of the chorion villi, which he believed penetrated 
the utricular glands of the decidua reflexa and absorbed gas from the 
hydroperione, or fluid situated between it and the decidua vera ; and 
in this manner he thought the foetal blood was oxygenated until 
the fifth month of intra-uterine life, when the placenta was fully 
formed. 

This hypothesis, however, rests on no accurate foundation, for it is 
certain that the chorion villi do not penetrate the utricular glands in the 
manner assumed ; or, even if they did, the mode in which the oxvgen 
thus absorbed by the chorion villi reaches the foetus, which is separated 
from them by the amnion and its contents, would still remain unex- 
plained. 

The mode in which the oxygenation of the foetal blood is effected 
before the formation of the placenta remains, therefore, as yet unknown. 
After the development of that organ, however, it is less difficult to 
understand, for the foetal blood is everywhere brought into such close 
contact with the maternal in the numerous minute ramifications of the 
umbilical vessels that the interchange of gases can readily be effected. 
The activity of respiration is doubtless much less than in extra-uterine 
life, for the waste of tissue in the foetus is necessarily comparatively 
small, from the fact of its being suspended in a fluid medium of its 
own temperature, and from the absence of the processes of digestion 
and of respiratory movements. The quantity of carbonic acid 
formed would, therefore, be much less than after birth, and there 
would be a correspondingly small call for oxygenation of venous 
circulation. 

Circulation. — The functions of the lungs being in abeyance, it is 
necessary that all the foetal blood should be carried to the placenta 
to receive oxygen and nutritive materials. To imderstand the mode 
in which this is effected we must bear in mind certain peculiarities 
in the circulatory system which disappear after birth. 

1. The two sides of the foetal heart are not separate as in the adult. 
The right ventricle in the adult sends all the venous blood to the lungs 
through the pulmonary arteries, to be aerated by contact with the 
atmosphere. In the foetus, however, only sufficient blood is passed 
through the pulmonary arteries to ensure their being pervious and 
ready to carry blood to the lungs immediately after birth. 

An aperture of communication, the /or«?«en ovcde, exists between the 
two auricles, which is arranged so as to permit the blood reaching the 
right auricle to pass freely into the left, but not vice versa. By this 
means a large portion of the blood reaching the heart through the 
ven?e cav{3e, instead of passing, as in the adult, into the right ventricle, 
is directed into the left auricle. 

2. Even with this arrangement, however, a larger portion of blood 




THE ANATOMY AND PHYSTOLOGY OF THE FfETUS. 133 

would pass into the pulmonary arteries than is required for transmis- 
sion to the lungs, and a further provision is made to prevent its going 
to them by means of a foetal vessel, the ductus 
arteriosus (Fig. 71), which arises from the ])ointof 
bifurcation of the pulmonary arteries and opens 
into the ar(;h of the aorta. In consequence of this 
arrangement only a very small portion of the 
blood reaches the lungs at all. 

3. The foetal hypogastric arteries are continued 
into large arterial trunks, which, passing into the 
cord, form the umhilical arteries and carry the 
impure foetal blood into the placenta. Diagram of Fcetai Heart. 

4. The purified blood is collected into the single ° (-^^^^r Daiton.) 
umhilical vein, through which it is carried to the 2, pSimonary artery-. 
under surface of the liver, from which point it is | Lcl'XL'iJr'''''- 
conducted, by means of another special fa'tal vessel, 

the ductus venosus, into the ascendino; vena cava and the rio^ht auricle. 

In order to understand the course of the foetal blood, it may be most 
conveniently traced from the point wliere it reaches the under surface 
of the liver through the umbilical vein. Part of it is distributed to the 
liver itself, but the greater quantity is carried directly into the inferior 
vena cava through the ductus venosus. Tlie inferior vena cava also 
receives the blood from the foetal veins of the lower extremities and 
that portion of the blood of the umbilical veiu which has passed through 
the liver. This mixed blood is carried up to the right auricle, from 
which by far the greater part of it is immediately directed into the 
left auricle through the foramen ovale. Thence it passes into the left 
ventricle, which sends the greater part of it into the head and upper 
extremities through the aorta, a comparatively small quantity being 
transmitted to the inferior extremities. The blood which is thus sent 
to the upper part of the body is collected into the vena cava superior, 
by which it is thrown into the right auricle. Here the mass of it is 
probably directed into the right ventricle, which expels it into the 
pulmonary arteries, and thence, through the ductus arteriosus, into 
the descending aorta. By this arrangement it will be seen that the 
descending aorta conveys to the lower part of the body the com]>ara- 
tively impure blood which has already circulated through the head, 
neck, and upper extremities. From the descending aorta a small quan- 
tity of blood is conveyed to the lower extremities, the greater part of 
it being carried for purification to the placenta through the umbilical 
arteries. 

As soon as the child is born it generally cries loudly anil inflates its 
lungs, and, in consequence, the pulmonary arteries are dilated, and 
the greater portion of the blood of the right ventricU^ is ar once sent 
to the lungs, whence, after being arterialized, it is returned \o the lett 
auricle through the ])ulmonary veins. Tlie left aurii'le, theret\>re, 
receives more blood than before, the right less, and, tlie placental circu- 
lation being arrested, no i\iore passes through the umbilical vein. In 
consequence of this, the pressure of the blood in the two auricles is 
equalized ; th(^ mass of the blood in the right auricle no louder passes 



134 PEEGNAXCY. 

into the left (the valve of the foramen ovale being closed bv the equal 
pressure on both sides), but directly into the right ventricle, and thence 
into the pulmonary arteries, and the ductus arteriosus soon collapses 
and becomes impervious. The mass of blood in the descending aorta 
no longer finds its way into the hypogastric arteries, but passes into 
the lower extremities, and the adult circulation is established. 

The changes which take place in the temporary vascular arrange- 
ments of the foetus prior to their complete disappearance are of some 
practical interest. The ductus arteriosus, as has been said, collapses, 
chiefly because the mass of blood is drawn to the lungs, and partly, 
perhaps, by its own inherent contractility. Its walls are found to be 
thickened, and its canal closes, first in the centre, and subsequently 
at its extremities, its aortic end remaining pervious longer on account 
of the greater pressure of blood from the left side of the heart (Fig. 72). 

Practical closure occurs within a few davs 
^^^- ''^- after birth, although Flourens states that it 

is not completely obliterated until eighteen 
months or two years have elapsed.^ Accord- 
ing to Schroeder, its walls unite without the 
formation of any thrombus. The foramen 
ovale is soon closed by its valve, which con- 
tracts adhesion with the edges of the aper- 
ture, so as efPectually to occhide it. Some- 
times, however, a small canal of communi- 
cation between the two auricles may remain 
pervious for many months, or even a year 
Diagram of Heart of Infant. ^^^^ more, without, howevcr, any admixture 
(After Daiton.) ^f 1)\qq^ occurrinp;. A permanentlv patu- 

1. Aorta. 2. Pnlmonars- artery. , -,.. n ,-i • , i*' 

3. 3. Pnlmonnrv brandies. " loUS COUdltlOn 01 tuiS apCrtUrC, llOWCVCr, 

4. ^Ductus axteriosus becoming oblite- g^metimCS CxistS, giviug rise tO the disCase 

known as cyanosis. 

The umbilical arteries and veins and the ductus venosus soon also 
become impermeable, in consequence of concentric hypertrophy of their 
tissue and collapse of their walls. The closure of the former is aided 
by the formation of coagula in the interior. According to Robin, a 
longer time than is usually supposed elap.ses before they become com- 
pletely closed, the vein remaining pervious until the twentieth or 
thirtieth dav after deliverv, the arteries for a month or six weeks. 
He has also described ^ a remarkable contraction of the umbilical 
ves.sels within their sheaths at the point where they leave the abdomi- 
nal walls, which takes place within three or four days after birth, and 
seems to prevent hemorrhage taking place when the cord is detached. 

The liver, from its proportionately large size, apparently plays an 
important part in the foetal economy. It is not until about the fifth month 
of utero-gestation that it assumes its characteristic structure and forms bile, 
previous to that time its texture being soft and undeveloped. Accord- 
ing to Claude Bernard, after this period one of its most important offices 
is the formation of sugar, which is found in much larger amount in the 
foetus than after birth. Sugar is, however, found in the foetal structures 

1 Acad, des Sciences, 1854. ^ jf,i^_^ igGO. 




THE ANATOMY AND PHYSIOLOGY OF THE F(ETUS. 135 

long before the development of the liver, especially in the mucous and 
cutaneous tissues; and it seems probable that these, as well as the pla- 
centa itself, then fulfil the glycogenic function, afterward chiefly per- 
formed by the liver. The bile is secreted after the fifth month of preg- 
nancy, and passes into the intestinal canal, and is subsequently collected 
in the gall-bladder. By some physiologists it has been supposed that 
the liver, during intra-uterine life, was the chief seat of depuration of 
the carbonic acid contained in the venous blood of the foetus. It is, 
however, more generally believed that this is accomplished solely in the 
placenta. The bile, mixed with the mucous secretion of the intestinal 
tract, forms the meconium which is contained in the intestines of the 
foetus, and which collects in them during the whole period of intra- 
uterine life. It is a thick, tenacious, greenish substance, which is voided 
soon after birth in considerable quantity. 

Urine is certainly formed during intra-uterine life, as is proved by 
the fact, familiar to all accoucheurs, that the bladder is constantly 
emptied instantly after birth. It has generally been supposed that the 
foetus voids its urine into the cavity of the amnion ; and the existence 
of traces of urea in the liquor amnii, as well as some cases of imperfo- 
rate urethra in which the bladder was found to be enormously distended,. 
and some cases of congenital hydronephrosis associated with impervious 
ureters, have been supposed to corroborate this assumption. The ques- 
tion has been very fully studied by Joulin, who has collected together a 
large number of instances in which there was imperforate urethra with- 
out any undue distension of the bladder. He holds, also, that the 
amount of urea found in the liquor amnii is far too minute to justifv the 
conclusion that the urine of the foetus was habitually passed into it, 
although a small quantity may, he thinks, escape into it from time to 
time; and he therefore believes that the urine of the foetus is only 
secreted regularly and abundantly after birth, and that during intra- 
uterine life its retention is not likely to give rise to any functional 
disturbance.^ 

Function of the Nervous System. — There is no doubt that the 
nervous system acts to a considerable extent during intra-uterine life, 
and some authors have even supposed that the foetus Avas endowed with 
the power of making instinctive or voluntary movements for the pur- 
pose of adapting itself to the form of the uterine cavity. ]\lost probably, 
however, the movements the foetus performs are purely reflex. That 
it responds to a stinudus applied to the cutaneous nerves is proved by 
the experiments of Tyler Smith, who laid bare the amnion in pregnant 
rabbits, and found that the foetus moved its limbs when these were irri- 
tated through it. Pressure on the mother's abdomen, cold a}>plications, 
and similar stimuli will also produce energetic fa^tal movements. 
The gray matter of the brain in the newborn child is, however, quite 
rudimentary in its structure, and there is no evidence *^( intelligent 
action of the nervous system until some timeat'ter birth, and, a fortiori, 
during pregnancy. 

^ Acad, des Scit')H't\<, p. 308. 



136 PREGNANCY. 



CHAPTER III. 
PKEGNANCY. 

Changes in the Uterus. — As soon as conception has taken place a 
series of remarkable changes commence in the uterus, which progress 
until the termination of pregnancy, and are well worthy of careful 
study. They produce those marvellous modifications which effect the 
transformation of the small undeveloped uterus of the non-pregnant 
state into the large and fully-developed uterus of pregnancy, and have 
no parallel in the whole animal economy. 

A knowledge of them is essential for the proper comprehension of 
the phenomena of labor, and for the diagnosis of pregnancy which the 
practitioner is so frequently called upon to make. Excluding the varie- 
ties of abnormal pregnancy, which will be noticed in another place, we 
shall here limit ourselves to the consideration of the modifications of the 
maternal organism which result from simple and natural gestation. 

The unimpregnated uterus measures 2J inches in length, and weighs 
about 1 ounce, while at the full term of pregnancy it has so immensely 
grown as to weigh 24 ounces and measure 12 inches. The growth com- 
mences as soon as the ovum reaches the uterus, and continues uninter- 
ruptedly until delivery. In the early months the uterus is contained 
entirely in the cavity of the pelvis, and the increase of size is only 
apparent on vaginal examination, and that with difficulty. Before the 
third month the enlargement is chiefly in the lateral direction, so that 
the whole body of the uterus assumes more of a spherical shape than in 
the non-pregnant state. If an opportunity of examining the gravid 
uterus 2^ost-mortem should occur at this time, it will be found to have 
the form of a sphere flattened somewhat posteriorly and bulging ante- 
riorly. 

After the ascent of the organ into the abdomen it develops more in 
the vertical direction, so that at term it has the form of an ovoid, with its 
large extremity above and its narrow end at the cervix uteri, and its 
longitudinal axis corresponds to the long diameter of the mother's abdo- 
men, provided the presentation be either of the head or breech. The 
anterior surface is now even more distinctly projecting than before — a 
fact wliich is explained by the proximity of the posterior surface to the 
rigid spinal column behind — while the anterior is in relation with the 
lax abdominal parietes, which yield readily to pressure, and so allow of 
the more marked prominence of the anterior uterine wall. 

Before the gravid uterus has risen out of the pelvis no appreciable 
increase in the size of the abdomen is perceptible. On the contrary, it 
is an old observation that at this early state of pregnancy the abdomen 
is flatter than usual, on account of the partial descent of the uterus in 
the pelvic cavity as a result of its increased weight. As the growth of 
the organ advances it soon becomes too large to be contained any longer 



PREGNANCY. 



187 



within the pelvis, and about tlie middle of the third or the beginning 
of the fourth month the fundus rises above the pelvic brim — not sud- 
denly, as is often erroneously thought, but slowly and gradually — when 
it may be felt as a smooth rounded swelling. 

It is about this time that the movements of the foetus first become 
appreciable to the mother, when " quickeninc/ '^ is said to have taken 
place. Toward the end of the fourth month the uterus reaches to 
about three fingers' breadth above the symphysis pubis. About the 
fifth month it occupies the hypogastric region, to which it imparts a 
marked projection, and the: alteration in the figure is now distinctly per- 
ceptible to visual examination. About the sixth month it is on a level 
with, or a little above, the umbilicus (Fig. 73). About the seventh 



Fig 73. 




Relations of the Pregnant Uterus at Sixth INUnith to the Surroiimling Tarts. i^Atter >[artin.) 

month it is about two inches above the umbilicus, which is now })rojcot- 
ing and prominent, instead of depressed, as in the uon-preguant state. 
During the eighth and ninth months it continues to increase until the 
summit of the fundus is immedi:iti>ly below the ensitorui cartilage 
(Fig. 74). A knowledge of the size of the uterine tiimcn- at various 
periods of pregnancy, as thus indicated, is of considerable practical im- 
portance, as forming the only giiidi> by which we can estimate the \n-oh- 
able period of delivery in certain cases in which the usual tlata tor cal- 



138 



PREGXAXCY. 



Fig. 74. 




Size of Uterus at Various Periods of Preg- 
nancy. 



dilation are absent ; as, for example, when the patient has conceived 
daring lactation. 

For about a week or more before labor the uterus generally sinks some- 
what into the pelvic cavity, in conse- 
quence of the relaxation of the soft 
parts which precedes delivery, and the 
patient now feels herself smaller and 
lighter than before. This change is 
familiar to all childbearins: women, to 
whom it is known as " the lightening 
before labor." 

AVhile the uterus remains in the pel- 
vis its longitudinal axis varies in direc- 
tion, much in the same way as that of 
the non-pregnant uterus, sometimes be- 
ing more or less vertical, at others in a 
state of anteversion or partial retrover- 
sion. These variations are probably de- 
pendent on the distension or emptiness 
of the bladder, as its state must neces- 
sarily affect the position of the movable 
organ poised behind it. After the uterus 
has risen into the abdomen its tendency 
is to project forward against the abdom- 
inal wall, which forms its chief support 
in front. In the erect position the long axis of the uterine tumor cor- 
responds with the axis of the pelvic brim, forming an agle of about 30° 
with the horizon. In the semi-recumbent position, on the other hand, 
as Duncan^ has pointed out, its direction becomes much more nearly 
vertical. In women who have borne many children the abdominal 
parietes no longer afford an efficient support, and the uterus is displaced 
anteriorly, the fundus in extreme cases even hanging downward. 

In addition to this anterior obliquity, on account of the projection of 
the spinal column, the uterus is very generally also displaced laterally, 
and sometimes to a very marked degree, so that it may be felt entirely 
in one flank, instead of in the centre of the abdomen. In a large pro- 
portion of cases this lateral deviation is to the right side, and many 
hypotheses have been brought forward to explain this fact, none of them 
being satisfactory. Thus, it has been supposed to depend on the greater 
frequency with which women lie on their right side during sleep, on the 
greater use of the right leg during walking, on the supposed compara- 
tive shortness of the right round ligament which drags the tumor to that 
side, or on the frequent distension of the rectum on the left side, vrhich 
prevents the uterus being displaced in that direction. Of these, the last 
is the cause which seems most constantly in operation, and most likely 
to produce the effect. 

The cervix must obviously adapt itself to the situation of the body 
of the uterus. We find, therefore, that in the early months, when the 
uterus lies low in the pelvis, it is more readily within reach. After the 

^ Researches in Obstetrics, p. 10. 



PREGNANCY. 139 

ascent of the uterus it is drawn up, and frequently so much so as to Ije 
reached with difficulty. When the uterus is much anteverted, as is so 
often the case, the os is displaced backward, so that it cannot be felt at 
all by the examining finger. 

Toward the end of j)regnan(y the greater part of the anterior surface 
of the uterus is in contact with the abdominal wall, its lower portion 
resting on the posterior surface of the sym])hysis pubis. The posterior 
surface rests on the spinal column, while the small intestines are pushed 
to either side, the large intestines surrounding the uterus like an arch. 

Chang-es in the Uterine Parietes. — The great distension of the 
uterus during pregnancy was formerly supposed to be mainly due to the 
mechanical pressure of the enlarging ovum within it. If this were so, 
then the uterine walls would be necessarily much thinner than in the 
non-pregnant state. This is well known not to be the case, and the 
immense increase in the size of the uterine cavity is to be explained 
by the hypertrophy of its walls. At the full period of pregnancy the 
thickness of the uterine parietes is generally about the same as that of 
the non-pregnant uterus, rather more at the placental site, and less in 
the neighborhood of the cervix. Their thickness, however, varies in 
different places, and in some women they are so thin as to admit of the 
foetal limbs being very readily made out by palpation. Their density 
is, however, always much diminished, and, instead of being hard and 
inelastic, they become soft and yielding to pressure. This change coin- 
cides with the commencement of pregnancy, of which it forms, as recog- 
nizable in the cervix, one of the earliest diagnostic marks. At a more 
advanced period it is of value as admitting a certain amount of yielding 
of the uterine walls to movements of the foetus, thus lessening the 
chance of their being injured. Bandl has pointed out that during the 
latter months of pregnancy the lower segment of the uterus, to a dis- 
tance of from four to six inches above the inner os, is thinner and less 
vascular than the tissues of the body of the uterus above. This thinner 
portion is separated from that above it by a ridge, often easily made 
out when the hand has to be inserted into the uterus after deliverv, 
known as " Bandl's ring." ^ 

Changes in the Cervix during- Pregnancy. — Very erroneous views 
have long been taught, in most of our standard works on midwiferv, as 
to the changes which oc(;ur in the cervix uteri during pregnancy. It 
is generally stated that, as pregnancy advances, the cervical cavity is 
greatly diminished in length, in consequence of its being graduallv 
drawn up so as to form part of the general cavity of the uterus, so that 
in the latter months it no longer exists. In almost all midwitery works 
accurate diagrams are given of this progressive shortening of the cervix 
(Figs. 75 to 78). The cervix is generally described as liaving lost (^no- 
half of its length at the sixth month, two-thirds at the seventh, anvl to 
be entirely obliterated in the eighth and ninth. The eorivciness ot* 
these views were iirst called in (nu>stion in recent times bv Stoltz in 
1826, but Dr. Dimcan,- in an elaborate historical paper on the subject, 

^ Veber dan Vcrhaltt-n dvs Uterus itnd Cfrrix in dcr Schwa)U)trsch(tft umi uiihri-nd dcr 
Odmrf, 1876. 

^ Bvsewrhvs in Obstdrics. 



140 



PEEGNAXCY. 



has shown that Stoltz was anticipated bv Weitl)rech in 1750, and, to a 
less degree, by Roederer and other writers. This opinion is now pretty 
generally admitted to be correct, and is upheld by Cazeaux, Arthur 



Fig. 75. 



Fig. 7( 





Fig. 77. 



Fig. 78. 





Supposed Shortening of the Cervix at the Third, Sixth, Eighth, and Ninth Months of Preg- 
nancy, as figured in obstetric works. 

Farre, Duncan, and most modern obstetricians. Indeed, various post- 
mortem examinations in advanced pregnancy have shown that the cavity 
of the cervix remains in reality of its normal length of one inch, and it 

Fig. 79. 




Cervix from a Woman dying in the Eighth Month of Pregnancy. (After Duncan.) 



PREGNANCY. 141 

can often be measured during life by the examining finger on account of 
its patulous state (Fig. 79). During the fortnight immediately preced- 
ing delivery, however, a real shortening or obliteration of the cervical 
cavity takes place, commencing above, until the cervical canal is merged 
into the uterine cavity ; but this, as Duncan has pointed out, seems to 
be due to the incipient uterine contractions which prepare the cervix 
for labor. 

There is, no doubt, an apparent shortening of the cervix always to be 
detected during pregnancy, but this is a fallacious and deceptive feeling, 
due to the softness of the tissue of the cervix, which is exceedingly 
characteristic of pregnancy, and which to an experienced finger affords 
one of its best diagnostic marks. 

In the non-pregnant state the tissue of the cervix is hard, firm, and 
inelastic. When conception occurs, softening begins at the external os, 
and proceeds gradually and slowly upward until it involves the whole 
of the cervix. By the end of the fourth month both lips of the os are 
thick, soft, and velvety to the touch, giving a sensation likened by 
Cazeaux to that produced by pressing on a table through a thick, soft 
cover. By the sixth month at least one-half of the cervix is thus 
altered, and by the eighth the whole of it ; and so much so that at this 
time those unaccustomed to vaginal examination experience some dif- 
ficulty in distinguishing it from the vaginal walls. It is this softening, 
then, which gives rise to the apparent shortening of the cervix so gen- 
erally described ; and it is an invariable concomitant of pregnancy, 
except in some rare cases in which there has been antecedent morbid 
induration and hypertrophic elongation of the cervix. If, therefore, on 
examining a woman supposed to be advanced in pregnancy, Ave find 
the cervix to be hard and projecting into the vaginal canal, we may 
safely conclude that pregnancy does not exist. The existence of soften- 
ing, however, it must be remembered, will not itself justify an opposite 
conclusion, as it may be produced, to a very considerable extent, by 
various pathological conditions of the uterus. 

At the same time that the tissue of the cervix is softened, its cavitv is 
widened and the external os becomes patulous. This change varies 
considerably in primiparas and multiparse. In the former the extei-nal 
OS often remains closed until the end of pregnancy; but even in them 
it generally becomes more or less patulous after the seventh month, and 
admits the ti]) of the examining finger. In women who have borne 
children this change is nuicli more marked. The lips of the external os 
are in them generally fissured and irregular, from slight lacerations i>f 
its tissue in former labors. It is also sufiiciently open \o admit the tip 
of the finger, so that in iha latter months of pregnancv it is often quite 
possible to toucli the membranes and through them to feel tlie ]->reseiu- 
ing part of the child. 

The remarkable increase in size of the uterus durino; preonanev is, as 
we have seen, chiefiy to be explained by the growth of its structures, all 
of which are modified during gestation. The peritoneal coverino- is con- 
siderably increased, so as still to form a complete coverino- to tlu^ morns 
when at its largest size. AVilliam Hunter supposed that its extension 
was effected rather bv the unfolding" of the lavers of the broad ligament 



142 PEEGXAXCY. 

than bv growth. Tliat the hi vers of the broad ligament do unfold 
during gestation, especially in the early months, is probable ; but this 
is not sufficient to account for the complete investment of the ute- 
rus, and it is certain that the peritoneum grows pari passu with 
the enlargement of the uterus. In addition, there is a new forma- 
tion of fibrous tissue between the peritoneal and the muscular coats, 
which affords strength and diminishes the risk of laceration during 
labor. 

The hypertrophy of the muscular tissue of the uterus is, however, the 
most remarkable of the changes produced by pregnancy. Not only do 
the previously existing rudimentary fibre-cells become enormously 
increased in size — so as to measure, according to Kolliker, from seven 
to eleven times their former length and from two to five times their for- 
mer breadth — but new unstriped fibres are largely developed, especially 
in the inner layers. These new cells are chiefly found in the first 
months of pregnancy, and their growth seems to be completed by the 
sixth month. The connective tissue between the muscular layers is also 
largely increased in amount. The weight of the muscular tissue of the 
gravid uterus is therefore much increased, and it has been estimated by 
Heschl that it weighs at term from 1 to 1.5 pounds; that is, about six- 
teen times more than in the unimpregnated state. This great develop- 
ment of the muscular tissue admits of its dissection in a way which is 
quite impossible in the unimpregnated state, and the researches of Helie 
(]). 61) enable us to understand much better than before how the mus- 
cles forming the walls of the gravid uterus act "during the expulsion of 
the child. 

The changes in the mucous coat of the uterus which result in the for- 
mation of the decidua, have already been discussed at length elsewhere 
(p. 101). 

The circulatory apparatus of the uterus during pregnancy has been 
described when the anatomy of the placenta was under consideration 

The lymphatics are much increased in size ; and recent theories on the 
production of certain ])uerperal diseases attribute to them a more 
important action than has been commonly assigned to them. 

The question of the growth of the nerves has been hotly discussed. 
Robert Lee took the foremost place among those who maintained that 
the nerves of the uterus share the general growth of its other constitu- 
ent parts. Dr. Snow Beck, however, believed that they remain of the 
same size as in the unimpregnated state, and this view is supported by 
Hirschfeld, Robin, and other recent writers. Robin thought that there 
is an apparent increase in the size of the nerve-tubes, which, however, 
is really due to increase in the neurilemma. Kilian describes the nerves 
as increasing in length, but not in thickness, while Schroeder states that 
they participate equally with the lymphatics in the enlargement the lat- 
ter undergo. Whichever of these views may ultimately be found to be 
correct, it is certain that analogy would lead us to expect an increase of 
nervous as well as of vascular supply. 

General Modifications in the Body produced by Preg-nancy. — It 
is not in the uterus alone that pregnancy is found to produce modifica- 



PREGNANCY. 143 

tions of importance. There are few of the more important functions of 
the body which are not, to a greater or less extent, affected : to some of 
these it is necessary briefly to direct attention, inasmuch as, when carried 
to excess, they produce those (hsorders whicli often complicate gestation, 
and which prove so distressing and even dangerous to tiie patients. Such 
of them as are apparent and may aid us in diagnosis are discussed in the 
chapter which treats of the signs and symptoms of pregnancy : in this 
place it is only necessary to refer to those which do not properly fall 
into that category. 

Amongst those which are most constant and important are the altera- 
tions in the composition of the blood. The opinion of the profession 
on this subject has of late years undergone a remarkable change. 
Formerly, it was universally believed that pregnancy was, as the rule, 
associated with a condition analogous to plethora, and that this ex- 
plained many characteristic phenomena of common occurrence, such as 
headache, palpitation, singing in the ears, shortness of breath, and the 
like. As a consequence, it was the habitual custom — not yet by any 
means entirely abandoned — to treat pregnant women on an antiphlo- 
gistic system, to place them on low diet, to administer lowering reme- 
dies, and very often to practise venesection, sometimes to a surprising 
extent. Thus it was by no means rare for women to be bled six or 
eight times during the latter months, even when no definite symptoms 
of disease existed ; and many of the older authors record cases where 
depletion was practised every fortnight as a matter of routine, and, 
when the symptoms were well marked, even from fifty to ninety 
times in the course of a single pregnancy. 

Composition of the Blood in Pregnancy. — Numerous careful 
analyses have conclusively proved that the composition of the blood 
during pregnancy is very generally — perhaps it would not be too much 
to say always — profoundly altered. Thus it is found to be more watery, 
its serum is deficient in albumen, and the amount of colored globules 
is materially diminished, averaging, according to the analysis of Bec- 
querel and Rodier, 111.8 against 127.2 in the non-gravid state. At 
the same time, the amount of fibrin and of extractive matter is consid- 
erably increased. The latter observation is of peculiar imjxirtance, and 
it goes far to explain the frequency of certain thrombotic atfections ob- 
served in connection with pregnancy and delivery : this hyperinosis of 
the blood is also considerably increased after labor by the quantity of 
effete material thrown into the mother's system at that time, to be got 
rid of by her emunctories. The truth is, that the blood of the jn-eg- 
uant woman is generally in a state nuich more nearly approaching the 
condition of anaemia than of })lethora, and it is certain that most of the 
phenomena attributed to plethora may be explained equally well and 
better on this view. These changes are nuich nu>re stronglv marked at 
the latter end of pregnancy than at its commencement, and it is inter- 
esting to observe that it is then tliat the conciMuitani phenomena alhuUnl 
to are most frequently met with, (''azeaux, to mIioui wo are chietly 
indebted for insisting on 'the practical bearing of these views, contends 
that the pregnant state is essentially analogous to chUn'osis, and that it 
should be so treated. ^lore recentlv, the accurate observations ot' ^\*ill- 



144 PEEGNANCY. 

cocks ^ have shown that tlie blood of pregnancy differs from that of 
chlorosis in the fact that while in both the amount of haemoglobin is 
lessened, in pregnancy the individual blood-cells are not impoverished 
as they are in chlorosis, but simply lessened in comparative number, 
owing to an increase in the water of the plasma, due to the progressive 
enlargement of the vascular area during gestation. Objection has not 
unnaturally been taken to Cazeaux's theory, as implying that a healthy 
and normal function is associated with a morbid state ; and it has been 
suggested that this deteriorated state of the blood may be a wise pro- 
vision of nature instituted for a purpose we are not as yet able to under- 
stand. It may certainly be admitted that pregnancy, in a perfectly 
healthy state of the system, should not be associated with phenomena 
in themselves in any degree morbid. It must not be forgotten, how- 
ever, that our patients are seldom — we might safely say never — in a 
state that is physiologically healthy. The influence of civilization, 
climate, occupation, diet, and a thousand other disturbing causes that, 
to a greater or less degree, are always to be met with, must not be left 
out of consideration. Making every allowance, therefore, for the un- 
doubted fact that pregnancy ought to be a perfectly healthy condition, 
it must be conceded, I think, that in the vast majority of cases coming 
under our notice it is not entirely so ; and the deductions drawn by 
Cazeaux from the numerous analyses of the blood of pregnant women 
seem to point strongly to the conclusion that the general blood-state is 
tending to poverty and anaemia, and that a depressing and antiphlo- 
gistic treatment is distinctly contraindicated. 

Modifications in Certain Viscera. — Closely connected with the 
altered condition of the blood is the physiological hypertrophy of the 
heart, which is now well known to occur during pregnancy. This was 
first pointed out by Larcher in 1828, and it has been since verified by 
numerous observers. It seems to be constant and considerable, and to 
be a purely physiological alteration intended to meet the increased exig- 
encies of the circulation which the complex vascular arrangements of 
the gravid uterus produce. The hypertrophy is limited to the left 
ventricle, the right ventricle, as well as both auricles, being unaffected. 
Blot estimates that the whole weight of the heart increases one-fifth 
during gestation. The more recent researches of Lohlein ^ render it 
probable that the hypertrophy is less than those authors have supposed. 
According to Duroziez,^ the heart remains enlarged during lactation, but 
diminishes in size immediately after delivery in women who do not 
suckle, w^hile in w^omen who have borne many children it remains per- 
manently somewhat larger than in nulliparse. Similar increase in the 
size of other organs has been pointed out by various writers ; as, for 
example, in the lymphatics, the spleen, and the liver. Tarnier states 
that in women who have died after delivery the organs always show 
signs of fatty degeneration. According to Gassner, the whole body 

^ " Comparative Observations on the Blood in Chlorosis and Pregnancy," by Fred. 
Willcocks, M. D. : The Lancet, December 3, 1881. 

^ Zeitschrift fiir Geburtshillfe und %naA*., 1876, Bd. i. S. 482: "Ueber das Verhalten 
des Herzens bei SchAvangerin u. Wochnerinnen." 

3 Qaz. des Hopit, 1868. 



PREGNANCY. 145 

increases in weight during the latter months of pregnancy, and this 
increase is somewhat beyond that which can be explained by the size of 
the womb and its contents. 

Formation of Osteophytes. — Irregular Ijony deposits between the 
skull and iha dura mater, in some cases so largely developed as to line 
the whole cranium, have been so frequently detected in women who 
have died during parturition that they are believed by some to h>e a nor- 
mal production connected with pregnancy. Ducrest found these osteo- 
phytes in more than one-third of the cases in which he performed post- 
mortem examinations during the puerperal period. E-okitansky, who 
corroborated the observation, believed this peculiar deposit of bony 
matter to be a physiological, and not a pathological, condition connected 
with pregnancy ; but whether it be so, or how it is produced, has not 
yet been satisfactorily determined. 

Changes in the Nervous System. — More or less marked changes 
connected with the nervous system are generally observed in pregnancy,, 
and sometimes to a very great extent. When carried to excess they 
produce some of the most troublesome disorders which complicate gesta- 
tion, such as alterations in the intellectual functions, changes in the dis- 
position and character, morbid cravings, dizziness, neuralgia, syncope, 
and many others. They are purely functional in their character, and 
disappear rapidly after delivery, and may be best described in connection 
with the disorders of pregnancy. 

Changes in the Respiratory Organs. — Respiration is often inter- 
fered with, from the mechanical results of the pressure of the enlarged 
uterus. The longitudinal dimensions of the thorax are lessened by the 
upward displacement of the diaphragm, and this necessarily leads to 
some embarrassment of the respiration, which is, however, compensated 
to a great extent by an increase in breadth of the base of the thoracic 
cavity. 

Changes in the Liver. — The liver has been observed to show cer- 
tain changes in pregnancy. Numerous small yellow spots are seen 
scattered through its substance, varying in size from a pin's head to a 
millet-seed ; and these are produced by fatty deposits in tlie hepatic cells, 
which De Sinety believes to be associated mainly with lactation and to 
disappear when that is concluded. 

Changes in the Urine. — Certain changes, which are of very constant 
occurrence, in the urine of pregnant women have attracted nuich atten- 
tion, and have been considered by many writers to be pathognomonic. 
They consist in the })resence of a peculiar deposit, formed when the 
urine has been allowed to stand for some time, which has received the 
name of klestcin. Its presence was known to the ancients, and ir was 
particularly mentioned by Savonarola in the fifteenth centurv, but it lias 
more especially been studied within the last thirtv vears bv KonisiiM-, 
Golding Bird, and others. If the urine of a pregnant woman bo 
allowed to stand in a cylindrical vessel, exposed to light and air, but 
protected from dust, in a period varying from two to seven davs a pecu- 
liar fiocculent sediment, lilce tine cotton-wool, makes its a|)pearanco in 
the centre of the fluid, and soon afterward rises to the surface and tbrnis 
a pellicle, which has been compared to the fat of cold mntton-broih. In 

10 



146 PBEGXAXCY. 

the course of a few clays the scum breaks up and falls to the bottom of 
the vessel. On microscopic examination it is found to be composed of 
fat-particles, with crystals of ammoniaco-magnesium phosphates and 
phosphate of lime, and a large quantity of vibriones. These appearances 
are generally to be detected after the second month of pregnancy, and 
up to the seventh or eighth month, after which they are rarely produced. 
Kegnauld explains their absence during the latter months of gestation 
by the presence in the urine at that time of free lactic acid, which 
increases its acidity and prevents the decomposition of the urea into car- 
bonate of ammonia. He believes that kiestein is produced by the action 
of free carbonate of ammonia on the phosphate of lime contained in the 
urine, and that this reaction is prevented by the excess of acid. 

Golding Bird believed kiestein to be analogous to casein, to the pres- 
ence of which he referred it, and he states that he has found it in 
27 out of 30 cases. Braxton Hicks so far corroborates his view, 
and states that the deposit of kiestein can be much more abundantly 
produced if one or two teaspoonfuls of rennet be added to the urine, 
since that substance has the property of coagulating casein. Much less 
importance, however, is now attached to the presence of kiestein than 
formerly, since a precisely similar substance is sometimes found in the 
urine of the non-pregnant, especially in ansemic women, and even in the 
urine of men. Parkes states that it is not of uniform composition, that 
it is produced by the decomposition of urea, and consists of the free 
phosphates, bladder-mucus, infusoria, and vaginal discharges. Xeuge- 
bauer and Vogel give a similar account of it, and hold that it is of no 
diagnostic value. That it is of interest as indicating the changes going 
on in connection with pregnancy is certain ; but inasmuch as it is not 
of invariable occurrence, and may even exist quite independently of 
gestation, it is obviously quite undeserving of the extreme importance 
that has been attached to it. 

Toward the end of pregnancy sugar may sometimes be detected in the 
urine, and after delivery and during lactation it exists in considerable 
abundance ; thus out of 35 cases tested in tlie Simpson Memorial Hos- 
pital in Edinburgh during the puerperium, it was found in all, the 
amount varying from 1 to 8 per cent.^ Kaltenbach has shown that this 
temporary glycosuria is due to the presence of milk-sugar in the urine, 
and that it ceases with the disappearance of milk from the breasts.^ 
Tliis physiological glycosuria must be carefully distinguished from true 
diabetes, which is a grave complication of pregnancy. 

Albumen is often present during the later stages of pregnancy, and it 
may be transitory and of comparatively little moment, although its 
presence must always be a cause of some anxiety. Leyden believes that 
it is most often met witli in the second half of a Jirst pregnancy, and it 
may become chronic, leading to granular atrophy of the kidneys.^ In 
some cases it seems to be the resuh of catarrhal conditions of the blad- 
der ; in others it is probably caused by undue arterial tension consequent 
on pregnancy. 

1 Edin. Med. Journ., vol. 1881-82, p. 116. 

2 Zeitf. Geburt. u. Gyn., 1879, Bd. iv. S. 161 : " Die Lactosiirie der Wocbnerinnen." 
^ Deutsche med. Wochensch., 1886, No. 9. 



SIGNS AND SYMPTOMS OF PREGNANCY. 147 



CHAPTER IV. 

SIGNS AND SYMPTOMS OF PREGNANCY. 

In attempting to ascertain the presence or absence of pregnancy 
the practitioner has before him a problem which is often beset with 
great difficulties, and on the proper solution of which the moral charac- 
ter of his patient, as well as his own professional reputation, may 
depend. The patient and her friends can hardly be expected to appre- 
ciate the fact that it is often far from easy to give a positive opinion on 
the point ; and it is always advisable to use much caution in the exam- 
ination, and not to commit ourselves to a positive opinion except on the 
most certain grounds. This is all the more important because it is just 
in those cases in which our opinion is most frequently asked that the 
statements of the patient are of least value, as she is either anxious to 
conceal the existence of pregnancy, or, if desirous of an affirmative 
diagnosis, unconsciously colors her statements so as to bias the judg- 
ment of the examiner. 

Constant attempts have been made to classify the signs of pregnancy; 
thus, some divide them into the natural and sensible signs, others into 
the 'presumptive, the probable, and the certain. The latter classification, 
which is that adopted by Montgomery in his classical w^ork on the 
Signs and Symptoms of Pregnanci/, is no doubt the better of the two, 
if any be required. The simplest way of studying the subject, hoAV- 
ever, is the one, now generally adopted, of considering the signs of 
pregnancy in the order in which they occur, and attaching to each an 
estimate of its diagnostic value. 

Signs of a Fruitful Conception. — From the earliest ages authors 
have thought that the occurrence of conception might be ascertained by 
certain obscure signs, such as a peculiar appearance of the eyes, swelling 
of the neck, or by unusual sensations connected with a fruitful inter- 
course. All of these, it need hardly be said, are far too uncertain to be 
of the slightest value. The last is a symptom on which many marrial 
Avomen profess themselves able to depend, and one to which Cazeaux is 
inclined to attach some importance. 

Cessation of Menstruation. — The first a]")preciable indication of 
pregnancy on which any dependence can be placed is the cessation ot^ 
the customary menstrual discharge ; and it is of great importance, as 
forming the only reliable guide for calculating the probable period of 
delivery. In women who have been previously }>erfectly regular, in 
whom there is no morbid cause which is likely to have produced su[)- 
pression, the non-ai)j)ea ranee of the catamenia may be taken as strong 
presumptive evidence of the existence of pregnancy ; but it can never 
be more than this, unless* verified and strengthened by other signs, 
iuasmuch as there are many conditions besides pregnancy wiiich may 
lead to its non-appearance. Thus, exposure to cold, mental emotion. 



148 FREGNANCY. 

general debility, especially when connected with incipient phthisis, may 
all have this effect. Mental impressions are peculiarly liable to mislead 
in this respect. It is far from uncommon in newly-married women to 
find that menstruation ceases for one or more periods, either from the 
general disturbance of the system connected w^ith the married life or 
from a desire on the part of the patient to find herself pregnant. Also 
in unmarried women who have subjected themselves to the risk of 
impregnation mental emotion and alarm often produce the same 
result. 

A further source of uncertainty exists in the fact that in certain cases 
menstruation may go on for one or more periods after conception or 
even during the whole pregnancy. The latter occurrence is certainly 
of extreme rarity, but one or two instances are recorded by Perfect, 
Churchill, and other writers of authority, and therefore its possibility 
must be admitted. The former is much less uncommon, and instances 
of it have probably come under the observation of most practitioners. 
The explanation is now well understood. During the early months of 
gestation, when the ovum is not yet sufficiently advanced in growth to 
fill the w^hole uterine cavity, there is a considerable space between the 
decidua reflexa which surrounds it and the decidua vera lining the ute- 
rine cavity. It is from this free surface of the decidua vera that the 
periodical discharge comes, and there is not only ample surface for it to 
come from, but a free channel for its escape through the os uteri. After 
the third month the decidua reflexa and the decidua vera blend together 
and the space between them disappears. Menstruation after this time 
is, therefore, much more difficult to account for. It is probable that in 
many supposed cases occasional losses of blood from other sources, such 
as placenta prsevia, an abraded cervix uteri, or a small polypus, have 
been mistaken for true menstruation. If the discharge really occurs- 
periodically after the third month, it can only come from the canal of 
the cervix. The occurrence, however, is so rare that if a woman is 
menstruating regularly and normally who believes herself to be more 
than four months advanced in pregnancy, we are justified ipso facto in 
negativing her supposition. [Menstruation in a pregnant woman may 
be due to the existence of a double uterus, one half of which is empty 
and free, while the other contains a foetus. The two halves or compart- 
ments may be impregnated at different periods, and give rise to a 
so-called superfoetation. — Ed.] In an unmarried woman all state- 
ments as to regularity of menstruation are absolutely valueless, for in 
such cases nothing is more common than for the patient to make false 
statements for the express purpose of deception. 

Conception may unquestionably occur when menstruation is nor- 
mally absent. This is far from uncommon in women during lactation, 
when the function is in abeyance, and who therefore have no reliable 
data for calculating the true period of their delivery. Authentic cases 
are also recorded in wliich young girls have conceived before menstrua- 
tion is established, and in w-hich pregnancy has occurred after the change 
of life. 

Taking all these facts into account, we can only look upon the cessa- 
tion of menstruation as a fairly presumptive sign of pregnancy in 



STGNS AND SYMPTOMS OF PREGNANCY. 149 

women in whom there is no clear reason to account for it, })ut one which 
is undoubtedly of great value in assisting our diagnosis. 

Shortly after conception various sympathetic disturbances of the sys- 
tem occur, and it is only very exceptionally that these are not estab- 
lished. They are generally most developed in women of highly ner- 
vous temperament ; and they are therefore most marked in patients in 
the upper classes of society, in whom this class of organization is most 
common. 

Morning" Sickness. — Amongst the most frequent of these are various 
disorders of tlie gastro-intestinal canal. Nausea or vomiting is very 
common ; and as it is generally felt on first rising from the recumbent 
position, it is popularly known amongst women as the '^ morning sick- 
ness.'* It sometimes commences almost immediately after conception, 
but more frequently not until the second month, and it rarely lasts after 
the fourth month. Generally there is nausea rather than actual vomit- 
ing. The woman feels sick and unable to eat her breakfast, and often 
brings up some glairy fluid. In other cases she actually vomits ; and 
sometimes the sickness is so excessive as to resist all treatment, seriously 
to affect the patient's health, and even imperil her life. These grave 
forms of the affection will require separate consideration. 

Very different opinions have been held as to the cause of morning 
sickness. Dr. Henry Bennet believes that, when at all severe, it is 
always associated with congestion and inflammation of the cervix uteri. 
Dr. Graily Hewitt maintains that it depends entirely on tlie flexion of 
the uterus, producing irritation of the uterine nerves at the seat of the 
flexion, and consequent sympathetic vomiting. This theory, when 
broached at the Obstetrical Society, was received with little favor : it 
seems to me to be sufficiently disproved by the fact, w^hich I believe to 
be certain, that more or less nausea is a normal and nearly constant 
phenomenon in pregnancy, for it is difficult to believe that nearly every 
pregnant w^oman has a flexed uterus. The generally received explana- 
tion is probably the correct one — viz. that nausea as well as other forms 
of sympathetic disturbance depends on the stretching of the uterine 
fibres by the growing ovum, and consequent irritation of the uterine 
nerves. It is therefore one, and only one, of the numerous reflex phe- 
nomena naturally accompanying pregnancy. It is an old observation 
that when the sickness of pregnancy is entirely absent, other (and gen- 
erally more distressing) sympathetic derangements are often met with, 
such as a tendency to syncope. Dr. Bedford^ has laid especial stress on 
this point, and maintains that under such circumstances women are 
peculiarly apt to miscarry. 

Other derangements of the digestive functions, de})ending on the 
same cause, are not uncommon, such as excessive or depraved ap]Hnite, 
the patient showing a craving for strange and even disgusting articles 
of diet. These cravings may be altogether irresistible, and are ]>opu- 
larly known as "longings." Ot' a similar charat'ter is the distiirlnHl 
condition of the bowels freqiuMitly observed, leading to const ipai ion. 
diarrluxw, and excei^sive flutidence. 

CVrtain glandidar sympathies may be developinl, one ot' the n\ost 

^ 7>/Vc<(.nvs ()/' ir()//)("« (!//(/ Children, p. ">r>l. 



150 PEEGNANCY. 

common being an excessive secretion from tlie salivary glands. A tend- 
ency to syncope is not uufrequent, rarely proceeding to actual fainting, 
but rather to tliat sort of partial syncope, unattended with complete loss 
of consciousness, which the older authors used to call " lypothemia/^ 
This often occurs in women who show no such tendency at other times, 
and, wdien developed to any extent, it forms a very distressing accom- 
paniment of pregnancy. Toothache is common, and is not rarely asso- 
ciated with actual caries of the teeth. When any of these phenomena 
are carried to excess, it is more than probable that some morbid condi- 
tion of the uterus exists, which increases the local irritation producing 
them. 

Mental Peculiarities. — Mental phenomena are very general. An 
undue degree of despondency, utterly beyond the patient's control, is 
far from uncommon ; or a change which renders the bright and good- 
tempered woman fractious and irritable ; or even the more fortunate, 
but less common, change by which a disagreeable disposition becomes 
altered for the better. 

All these phenomena of exalted nervous susceptibility are of but 
slight diagnostic value. They may be taken as corroborating more cer- 
tain signs, but nothing more ; and they are chiefly interesting from their 
tendency to be carried to excess and to produce serious disorders. 

Mammary Changes. — Certain changes in the mammse are of early 
occurrence, dependent, no doubt, on the intimate sympathetic relations 
at all times existing between them and the uterine organs, but chiefly 
required for the purpose of preparing for the important function of 
lactation which on the termination of pregnancy they have to per- 
form. 

Generally about the second month of pregnancy the breasts become 
increased in size and tender. As pregnancy advances they become 
much larger and firmer, and blue veins may be seen coursing over them. 
The most characteristic changes are about the nipples and areolae. The 
nipples become turgid, and are frequently covered with minute branny 
scales, formed by the desiccation of sero-lactescent fluid oozing from 
them. The areolae become greatly enlarged and darkened from the 
deposit of pigment (Fig. 80). The extent and degree of this discol- 
oration vary much in different women. In fair women it may be so 
slight as to be hardly appreciable ; while in dark women it is generally 
exceedingly characteristic, sometimes forming a nearly black circle 
extending over a great part of the breast. The areola becomes moist 
as well as dark in appearance, and is somewhat swollen, and a number 
of small tubercles are developed upon it, forming a circle of projections 
round the nipple. These tubercles are described by Montgomery as 
being intimately connected with the lactiferous ducts, some of which 
may occasionally be traced into them and seen to open on their sum- 
mits. As pregnancy advances they increase in size and number. During 
the latter months what has been called " the secondary areola " is pro- 
duced, and when well marked presents a very characteristic appearance. 
It consists of a number of minute discolored spots all round the outer 
margin of the areola, where the pigmentation is fainter, and whicli are 
generally described as resembling spots from which the color has been 



SIGNS AND SYMPTOMS OF PREGNANCY. 151 

discharged by a sliower of water-drops. This change, like the dark- 
ening of the primary areola, is more marked in brunettes. At this 
period, especially in women whose skin is of fine texture, whitish sil- 
very streaks arc often seen on the breasts. They are produced l^y the 
stretching of the cutis vera, and are permanent. 

By pressure on the breasts a small drop of serous-looking fluid can 
very generally be forced out from the nipple, often as early as the third 

Fig. 80. 



'^i 



£.-:: 



Appearance of the Areola in Pregnancy. 

month, and on microscopic examination milk- and colostrum-globules 
can be seen in it. 

The diagnostic value of these mammary changes has been variously 
estimated. When well marked they are considered by INlontgomery to 
be certain signs of pregnancy. To this statement, however, some 
important limitations must be made. In women who have never borne 
children they no doubt are so ; for, although various uterine and ova- 
rian diseases produce some darkening of the areola, they certainly never 
produce the well-marked changes above descn-ibed. In multipara^ 
however, the areoke remain permanently darkened, and in them these 
signs are much less reliable. In first pregnancies the presence of milk 
in the breasts may be considered an almost certain sign, and it is one 
Avhicih I have rarely failed to detect even from a comparatively early 
period. It is true that there are autlienticated instances of non-pregnant 
women having an abundant secretion of milk, established from mam- 
mary irritation. Thus, J^nudelocque presented to the Academy o( 
Surgery of Paris a young girl, eight years of age, who had nui-sinl her 
little brother for more than a month. Dr. Tanner states— I do not 
know on what authority — that " it is not uncomnu>n in Western Africa 
for young girls who have never been pregnant to regularly employ 



152 PREGNANCY. 

themselves iu nursing the children of others, the mammse being excited 
to action by the application of the juice of one of the Euphorbiacese/' 
Lacteal secretion has even been noticed in the male breast. But these 
exceptions to the general rule are so uncommon as merely to deserve 
mention as curiosities ; and I have hardly ever been deceived in diag- 
nosing a first pregnancy from the presence of even the minutest quantity 
of lacteal secretion in the breasts, although even then other corrobo- 
rative signs should always be sought for. In multiparse the presence 
of milk is by no means so valuable, for it is common for milk to remain 
in the mammse long after the cessation of lactation, even for several 
years. Tyler Smith correctly says that " suppression of the milk in 
persons who are nursing and liable to impregnation is a more valuable 
sign of pregnancy than the converse condition.'^ This is an observation 
I have frequently corroborated. 

As a diagnostic sign, therefore, the mammary appearances are of great 
importance in primipar?e, and when well marked they are seldom 
likely to deceive. They are specially important when we suspect preg- 
nancy in the unmarried, as w^e can easily make an excuse to look at the 
breast without explaining to the patient the reason ; and a single glance, 
especially if the patient be dark-complexioned, may so far strengthen 
our suspicion as to justify a more thorough examination. In married 
multiparse they are less to be depended upon. 

In connection with this subject may be mentioned various irregular 
deposits of pigment which are frequently observed. The most common 
is a dark-brownish or yellowish line starting from the pubes and run- 
ning up to the centre of the abdomen — sometimes as far as the umbilicus 
only, at others forming an irregular ring round the umbilicus and reach- 
ing to the epigastrium. It is, however, of very uncertain occurrence, 
being well marked in some women, while in others it is entirely absent. 
Patches of darkened skin are often observed about the face, chiefly on 
the forehead, and this bronzing sometimes gives a very peculiar appear- 
ance. Joulin states that it only occurs on parts of the face exposed to 
the sun, and that it is therefore most frequently observed in women of 
the lower orders who are freely exposed to atmospheric influences. 
These pigmentary changes are of small diagnostic value, and may con- 
tinue for a considerable time after delivery. [A contusion of the cheek 
in a pregnant woman will sometimes be followed by a dark-brown spot 
or liver-mark that may remain several months or less, according to the 
stage of gestation. We once saw a well-marked instance of this in a lady 
of Philadelphia, a young, multipara. — Ed.] 

Pcetal Movements. — The progressive enlargement of the abdomen 
and the size of the gravid uterus at various periods of pregnancy, as Avell 
as the method of examination by means of abdominal palpation, have 
already been described (pp. 127 and 137). 

We will now consider the well-known phenomena produced by the 
movements of the foetus in ufero which are so familiar to all pregnant 
women. These, no doubt, take place from the earliest period of foetal 
life at Avhich the muscular tissue of the foetus is sufficiently developed to 
admit of contraction, but they are not felt by the mother until some- 
^vhere about the sixteenth week of utero-gestation, the precise period at 



SIGNS AND SYMPTOMS OF PREGNANCY. 153 

Avhicli they are perceived varying considerably in different cases. The 
error of the law on this su})ject which supposes the child not to be alive, 
or '^ quick/' until the mother feels its movements, is well known, and 
has frequently been protested against by the medical ])rofession. The 
so-called quickeninr/ — which certainly is felt very suddenly by some 
women — is believed to depend on the rising of the uterine tumor suf- 
iiciently high to permit of the impulse of the foetus being transmitted to 
the abdominal walls of the mother, through the sensory nerves of which 
its movements become appreciable. The sensation is generally described 
as being a feeble fluttering, which when first felt not unfrequently causes 
unpleasant nervous sensations. As the uterus enlarges the movements 
become more and more distinct, and generally consist of a series of 
sharp blows or kicks, sometimes quite appreciable to the naked eye and 
causing distinct projections of the abdominal walls. Their force and 
frequency will also vary during pregnancy according to circumstances. 
At times they are very frequent and distressing ; at others the foetus 
seems to be comparatively quiet, and they may even not be felt for 
several days in succession, and thus unnecessary fears as to death of the 
foetus often arise. The state of the mother's health has an undoubted 
influence upon them. They are said to increase in force after a pro- 
longed abstinence from food or in certain positions of the body. It is 
certain that causes interfering with the vitality of the foetus often pro- 
duce very irregular and tumultuous movements. They can be very 
readily felt by the accoucheur on palpating the abdomen, and sometimes, 
in the latter months, so distinctly as to leave no doubt as to the exist- 
ence of pregnancy. They can also generally be induced by placing one 
hand on each side of the abdomen and applying gentle pressure, which 
will induce foetal motion that can be easily appreciated. 

As a diagnostic sign the existence of foetal movements has alwavs 
lield a high place, but care should be taken in relying on it. It is cer- 
tain that women are themselves very often in error, and fancy they feel 
the movements of a foetus when none exists, being probably deceived by 
irregular contractions of the abdominal nuiscles or flatus within the 
bowels. They may even involuntarily produce such intra-abdominal 
movements as may readily deceive the practitioner. Of course, in 
advanced pregnancy, when the foetal movements are so marked as to be 
seen as well as felt, a mistake is hardly possible, and they then ccm- 
stitute a certain sign. But in such cases there is an abundance of other 
indications and little room for doubt. In questionable cases and at an 
early period of ])regnancy the fact that movements are not felt nuist nor 
be taken as a proof of the non-existence of ])regnancy, for they mav be 
so feeble as not to be })erceptible, or they may be absent for a consider- 
able period. 

Braxton Hicks ^ has directed attiMition to the vahie, iVom a diagnostic 
point of view, of intcuMuittent contractions of th(^ uterus during- preg- 
nancy. Ailev the uterus is suiUciently large to bc^ felt by palpation, it' 
the hand be placed over it and it be grasjied tor a time withoiu using 
any friction or ])i'essure, it will be observinl to distiiu'tlv harden in a 
mannerthat is quite charai'teristie. This intermittent contraction oeeui-s 

^ Obst. Tmns., IST'J. vol. xiii. p. -\(\. 



154 PEEGNANCY. 

every five or ten minutes, sometimes oftener, rarely at longer intervals. 
The fact that the uterus did contract in this way had been previously 
described, more especially by Tyler Smith, who ascribed it to peristaltic 
action. But it is certain that no one before Dr. Hicks had pointed out 
the fact that such contractions are constant and normal concomitants of 
pregnancy, continuing during the whole period of utero-gestation, and 
forming a ready and reliable means of distinguishing the uterine tumor 
from other abdominal enlargements. Since reading Dr. Hicks' paper 
I have paid considerable attention to this sign, which I have never 
failed to detect, even in the retroverted gravid uterus contained entirely 
in the pelvic cavity, and I am disposed entirely to agree with him as to 
its great value in diagnosis. If the hand be kept steadily on the uterus, 
its alternate hardening and relaxation can be appreciated with the 
greatest ease. The advantages which this sign has over the foetal move- 
ments are that it is constant, that it is not liable to be simulated by 
anything else, and that it is independent of the life of the child, being 
equally appreciable when the uterus contains a degenerated ovum or 
dead foetus. The only condition likely to give rise to error is an 
enlargement of the uterus in consequence of contents other than the 
results of conception, such as retained menses or a polypus. The history 
of such cases — which are, moreover, of extreme rarity — would easily 
prevent any mistake. As a corroborative sign of pregnancy, therefore, 
I should give these intermittent contractions a high place. 

[In rare instances these intermittent contractions are accompanied by 
a sensation of pain, such as to alarm the patient and give rise to fears 
of a miscarriage ; but it will be found that the uterus gives no evidence 
of a design to expel its contents. In one case attended by the writer 
the pains lasted three weeks, and finally ceased under an opiate treat- 
ment, the contractions continuing, but without sensation : the foetus was 
born at maturity. — Ed.] 

The vag-inal signs of pregnancy are of considerable importance 
in diagnosis. They are chiefly the changes which may be detected in 
the cervix, and the so-called haUottement, which depends on the mobility 
of the foetus in the liquor amnii. 

Softening- of the Cervix. — The alterations in the density and appa- 
rent length of the cervix have been already described (p. 138). When 
pregnancy has advanced beyond the fifth month the j^eculiar velvety 
softness of the cervix is very characteristic, and affords a strong corrob- 
orative sign, but one which it would be unsafe to rely on by itself, 
inasmuch as very similar alterations may be produced by various 
causes. When, however, in a supposed case of pregnancy advanced 
beyond the period indicated the cervix is found to be elongated, dense, 
and projecting into the vaginal canal, the non-existence of pregnancy 
may be safely inferred. Therefore the negative value of this sign is 
of more importance than the positive. In connection with this may be 
mentioned a sign of pregnancy to which attention has recently been 
drawn by Hegar.^ It consists in a peculiar elasticity of the lower seg- 
ments of the uterus, made out by vaginal or rectal examination. It 
may serve to differentiate the pregnant uterus from certain uterine 
1 Centmlblait fur GyndL, 188G, Bd. xi. p. 805. 



S'IGNS AND SYMPTCMS OF PIlEfJ NANCY. 155 

enlargements due to tumors in those cases in which tlie diagnosis is 
doubtfuL 

Ballottement, when distinctly made out, is a very valua])le indica- 
tion of pregnancy. It consists in the displacement, by tlie examining 
finger, of the foetus, which floats up in the liquor amnii, and falls back 
again on the tip of the flnger with a slight tap which is exceedingly 
characteristic. 

In order to practise it most easily the patient is placed on a couch or 
bed in a position midway between sitting and lying, by which the ver- 
tical diameter of the uterine cavity is brought into correspondence with 
that of the pelvis. Two fingers of the right hand are then passed high 
up into the vagina in front of the cervix. The uterus being now 
steadied from without by the left hand, the intravaginal fingers press 
the uterine wall suddenly upward, when, if pregnancy exist, the foetus 
is displaced, and in a moment falls back again, imparting a distinct 
impulse to the fingers. When easily appreciable it may be considered 
as a certain sign, for although an anteflexed fundus or a calculus in the 
bladder may give rise to somewhat similar sensations, the absence of 
other indications of pregnancy would readily prevent error. Ballotte- 
ment is practised between the fourth and seventh months. Before the 
former time the foetus is too small, while at a later period it is relatively 
too large and can no longer be easily made to rise upward in the sur- 
rounding liquor amnii. The absence of ballottement must not be taken 
as proving the non-existence of pregnancy, for it may be inappreciable 
from a variety of causes, such as abnormal presentations or the implan- 
tation of the placenta upon the cervix uteri. 

Vaginal Pulsation. — There are also some other vaginal signs of 
pregnancy of secondary consequence. Amongst these is the vaginal 
pulsation, pointed out by Osiander, resulting from the enlargement of 
the vaginal arteries, which may sometimes be felt beating at an early 
period. Often this pulsation is very distinct, and at other times it can- 
not be felt at all, and it is altogether unreliable, as a similar pulsation 
may be felt in various uterine diseases. 

Uterine Fluctuation. — Dr. Rasch has drawn attention to a pre- 
viously undescribed sign which he believes to be of importance in the 
diagnosis of early })regnancy.^ It ccHisists in the detection of fluctua- 
tion througli the antei'ior uterine wall, depending on the presence of 
the liquor amnii. In order to make this out, two fingers of the right 
hand must be used, as in ballottement, while the uterus is steadied 
through the abdomen. Dr. Ilasch states that by this means the 
enlarged uterus in pregnancy can easily be distinguished Worn the 
enlargement depending on other causes, and that fluctuation can always 
be felt as early as the second month. If it is associated with suppressed 
menstruation and darkened areohe, he cn^nsiders it a certain sign. In 
order to detect it, however, considerable experience in making vaginal 
examinations is essential, and it can hardly be depiMuKHl on toi-giMUMal um\ 

A peculiar deep violet hue of the vaginal mucous nuMubrane was 
relied on by Jacquemin ^'and Kliige as atloriling a readily-observinl 

^ Brit. MtHl JoiiDK, 1S7;>. vol. ii. p. -lU. 

* The crotUt of (irst drawing- altcnliou to this siun ot' prounaiu'v is uonorally givon 



156 PEEGNANCY. 

indication of pregnancy. In most cases it is well marked ; sometimes^ 
indeed, the change of color is veiy intense, and it evidently dej^ends on 
the congestion produced by pressure of the enlarged uterus. Chad- 
wick has recently reinvestigated this sign, and attributes to it a high 
diagnostic value/ It has been generally stated to be unreliable, as 
a similar discoloration is said to be produced by the pressure of 
large uterine fibroids. This, however, Chadwick declares is not the 
case. 

Auscultatory Signs of Pregnancy. — By far the most important 
signs are those Avhich can be detected by abdominal auscultation, and 
one of these — the hearing of the foetal heart-sounds — forms the only 
sign which, per se and in the absence of all others, is perfectly reliable. 

The fact that the sounds of the foetal heart are audible during 
advanced pregnancy was first pointed out by Mayor of Geneva in 
1818, and the main facts in connection with foetal auscultation were 
subsequently worked out by Kergaradec, Naegele, Evory Kennedy, 
and other observers. The pulsations first become audible, as a rule, 
in the course of the fifth month or about the middle of the fourth 
month. In exceptional circumstances and by practised observers they 
have been heard earlier. Depaul believes that he detected them as 
early as the eleventh week, and Routh has also detected them at an 
earlier period by vaginal stethoscopy, which, however, for obvious 
reasons, cannot be ordinarily employed. Naegele never heard them 
before the eighteenth week, more generally at the end of the twen- 
tieth, and for practical purposes the pregnancy must be advanced to 
the fifth month before we can reasonably expect to detect them. From 
this period up to term they can almost always be heard, if not at 
the first attempt, at least afterward to a certainty, if we have the 
opportunity of making repeated examinations. Accidental circum- 
stances, such as the presence of an unusual amount of flatus in the 
intestines, may deaden the sounds for a time, but not permanently. 

Depaul only failed to hear them in 8 cases out of 906 examined 
during the last three months of pregnancy ; and out of 180 cases 
which Dr. Anderson of Glasgow carefully examined, he only failed 
in 12, and in each of these the child was stillborn. They therefore 
form not only a most certain indication of pregnancy, but of the life 
of the foetus also. 

The sound has always been likened to the double tic-tac of a 
watch heard through a pillow, which it closely resembles. It consists 
of two beats, separated by a short interval, the first being the loudest 
and most distinct, the second being sometimes inaudible. The ra- 
pidity of the foetal pulsations forms an important means of distin- 
guishing them from transmitted maternal pulsations, with which they 
might be confounded. Their average number is stated by Slater, 
who made numerous observations on this point, to be 132, but some- 

to Jacqnemier, a distingnisbed French obstetrician, wbo wrote a Avork on midwifery. 
It is due, bowever, to .Jacqnemin, medecin en cbef de la prison de Mazas, and is, in 
fact, attributed to him in Jacquemier's Avork [Manuel des Accouchemcnis, par J. Jacque- 
mier, Paris, 1846, vol. i. p. 215). 

^ Transactions of the American Gyncecological Society, 1886,^ vol. ii. p. 399. 



STGNS AND SYMPTOMS OF PREGNANCY. 157 

times they reach as high as 140, and sometimes as low as 120. It 
will thus be seen that the pulsations are always much more rapid 
than those of the mother's heart, unless, indeed, the latter be unduly 
accelerated by transient mental emotion or disease. To avoid mis- 
takes, whenever the foetal heart is heard its rate of pulsation should 
be carefully counted and compared with that of the mother's pulse ; 
if the rates differ, we may be sure that no error has been made. The 
rapidity of the foetal pulsations remains, as a rule, the same during 
the whole period of pregnancy, while their intensity gradually increases. 
They may, however, be temporarily increased or diminished in frequency 
by disturbing causes, such as the pressure of the stethoscope, which, 
exciting tumultuous movements of the foetus, may induce greatly 
increased frequency of its heart-beats. So also during labor, after the 
escape of the liquor amnii, when the contractions of the uterus have a 
very distinct influence on the foetus, they may be greatly modified. An 
acceleration or irregularity of the pulsations made out in the course of 
a prolonged labor may thus be of great practical importance, by indi- 
cating the necessity for prompt interference. Similar alterations, asso- 
ciated with tumultuous and unusual foetal movements felt by the mother 
toward the end of pregnancy, may point to danger to the life of the 
foetus during the latter months, and may even justify the induction of 
premature labor. This is especially the case in women who have pre- 
viously given birth to a succession of dead children owing to disease of 
the placenta, and in them careful and frequently repeated auscultations 
may warn us of the impending danger. 

The rapidity of the foetal heart has been supposed by some to afford 
a means of determining the sex of the child before birth. Franken- 
hauser, who first directed attention to this point, is of opinion that the 
average rate of pulsations of the heart is considerably less in male than 
in female children, averaging 124 in the minute in the former, as 
against 144 in the latter. Steinbach makes the difference somewhat 
less — viz. 131 for males and 138 for females. He predicted the sex 
correctly by this means in 45 out of 57 cases, Avhile Frankenhauser was 
correct in the whole 50 cases which he specially examined with reference 
to the point. Dr. Hutton of I^ew York ^ was also correct in 7 cases he 
fixed on for trial. Devilliers found the difference in the sexes to be the 
same as Steinbach: he attributes it, however, to the size and weight 
rather than to the sex of the child, and believes the pulsations to be 
least numerous in large and well-developed children. As male children 
are usually larger than female, he thus explains tiie relatively less fre- 
quent pulsations of their hearts. Dr. Cumming of Fdinlnirgh also 
believes that the weight of the child has considerable influence on 
the frequency of its cardiac pulsations, so that a large female child 
may have a slower pulse than a small male.^ The point, liowi^ver. is 
more curious than practical, and the rapidity of the ])ulsations certainly 
would not justily any j)ositive predictit^n on the subjeci. Oircum>tances 
influencing the maternal circulation seem to have no intluoneo on that 
of the fcL^tus. 

^ New York Med. Jouru., 187l\ vol. xvi. p. (iS. 

'^ Kiln. Mid. Jonrn., vol. 1875-7(>, pp. 'J;>0. ol7. 418. 



158 PBEGNAXCY. 

The f(jetal heart-sounds are generally propagated best by the back of 
the child, and are therefore most easily audible when this is in contact 
with the anterior wall of the uterus, as is the case in the large majority 
of pregnancies. When the child is placed in the dorso-posterior posi- 
tion the sounds have to traverse a larger amount of the liquor amnii, and 
are further modified by the interposition of the foetal limbs. They are, 
therefore, less easily heard in such cases, but even in them they can 
almost always be made out. As the foetus most frequently lies with the 
occiput over the brim of the pelvis, and the back of the child toward 
the left side of the mother, the heart-sounds are usually most distinctly 
audible at a point midway between the umbilicus and the left anterior 
superior spine of the ilium. In the next most common position, in 
which the back of the child lies to the right lumbar region of the 
mother, they are generally heard at a corresponding point at the right 
side, but in this case they are frequently more readily made out in the 
right flank, being then transmitted through the thorax of the child, 
which is in contact with the side of the uterus. In breech cases, on the 
other hand, the heart-sounds are generally heard most distinctly above 
the umbilicus, and either to the right or left according to the side 
toward which the back of the child is placed. It will thus be seen 
that the place at which the foetal heart-sounds are heard varies with the 
position of the foetus ; and this, when combined w^ith the information 
derived from palpation, affords a ready means of ascertaining the pres- 
entation of the child before labor. The sounds are only audible over 
a limited space, about two or three inches in diameter ; therefore, if we 
fail to detect them in one place, a carefnl exploration of the whole 
uterine tumor is necessary before we are satisfied that they cannot be 
heard. 

The only mistake that is likely to be made is taking the maternal 
pulsations, transmitted through the uterine tumor, for those of the foetal 
heart. A little care will easily prevent this error, and the frequency of 
the mother's pulse should always be ascertained before counting the sup- 
posed foetal pulsations. If these are found to be 120 or more, while the 
mother's pulse is only 70 or 80, no mistake is possible. If the latter is 
abnormally quickened, greater care may be necessary, but even then the 
rate of pulsation of each will be dissimilar. Braxton Hicks ^ has 
pointed out that in tedious labor, w^hen the muscular powers of the 
mother are exhausted, the muscular subsurrus may produce a sound 
closely resembling the foetal pulsation ; but error from this source is 
obviously very improbable. 

In listening for the foetal heart-sound the patient should be placed on 
her back, Avith the shoulders elevated and the knees flexed. The sur- 
face of the abdomen should be uncovered, and an ordinary stethoscope 
em])loyed, the end of which must be pressed firmly on the tumor, so as 
to depress the abdominal walls. The most absolute stillness is neces- 
sary, as it is often far from easy to hear the sounds. Sometimes, after 
failing with the ordinary stethoscope, I have succeeded with the bin- 
aural, which remarkably intensifies them. When once heard they are 
most easily counted during a space of five seconds, as on account of 

1 Obsl. Trans., 1874, vol. xv. p. 187. 



SIGNS AND SYMPTOMS OF PREGNANCY. 159 

their frequency it is not always possible to follow them over a 
longer period. 

When the foetal heart-sounds are heard distinctly, pregnancy may be 
absolutely and certainly diagnosed. The fact that we do not hear them 
does not, however, preclude the possibility of gestation, for the foetus 
may be dead or the sounds temporarily inaudible. 

Other Sounds heard in Preg-nancy. — There are some other sounds 
heard in auscultation which are of very secondary diagnostic value. One 
of these is the so-called umbilical ov funic souffle, which was first pointed 
out by Evory Kennedy. It consists of a single blowing murmur syn- 
chronous with the foetal heart-sounds, and most distinctly heard in the 
immediate vicinity of the point where these are most audible. Most 
authors believe it to be produced by pressure on the cord, either when 
it is placed between a hard part of the foetus and the uterine walls or is 
twisted round the child's neck. Schroeder and Hecker detected it in 14 
or 15 per cent, of all cases, and the latter believed it to be caused by 
flexure of the first portion of the cord near the umbilicus. For 
practical purposes it is quite valueless, and need only be mentioned 
as a phenomenon which an experienced auscultator may occasionally 
detect. 

The uterine souffle is a peculiar single whizzing murmur which is 
almost always audible on auscultation. It varies very remarkably in 
character and position. Sometimes it is a gentle blowing or even 
musical murmur ; at others it is loud, harsh, and scraping ; sometimes 
continuous, sometimes intermittent. It may also be heard at any point 
of the uterus, but most frequently low down and to one or other side, 
more rarely above the umbilicus or toward the fundus ; and it often 
changes its position so as to be heard at a subsequent auscultation at a 
point where it was previously inaudible. It may be heard over a space- 
of an inch or two only, or in some cases over the whole uterine tumor ; 
or, again, it may sometimes be detected simultaneously over two entirely 
distinct portions of the uterus. It is generally to be heard earlier than 
the foetal heart-sounds, often as soon as the uterus rises above the brim 
of the pelvis, and it can almost always be detected after the commence- 
ment of the fourth month. The sound becomes curiously modified by 
the uterine contractions during labor, becoming louder and more intense 
before the pain comes on, disappearing during its acme, and again being 
heard as it goes off. Hicks attributes to a similar cause — viz. the uterine 
contractions during pregnancy — the frequent variations in the sound 
which are characteristic of it.^ The uterine souffle is also audible after 
the death of the fa^tus, and it is believed by some to be nuxlitiod and to 
become more continuausly harsh when tiiat event has taken }>la('e. 

Very various explanations have been given of the causes of this soiuul. 
For long it was su})posed to be formed in the vessels of the plawnta, and 
hence i\\(i name ^^ placental souffle'^ by which it is often talkixl of, or, if 
not in the placenta, in the uterine vessels in its immetliate neighborluHnl. 
The non-])lacental origin of the sound is suihciently denn>nstra(ed bv the 
fact that it may be heard fhr a considerable time after the expulsion ot' 
the placenta. Some have sii})posetl that it is not tonned in the uterus at 

' Op. (•('/., p. -J-Jo. 



160 PREGNANCY. 

all, but in the maternal vessels, especially the aorta and the iliac arteries^ 
OAving to the pressure to which they are subjected by the gravid uterus. 
The extreme irregularity of the sound, its occasional disappearance, and 
its variable site seem to be conclusive against this view. The theory 
which refers the sound to the uterine vessels is that which has received 
most adherents, and which best meets the facts of the case; but it is by 
no means easy, or even possible, to account for the exact mode of its pro- 
duction in them. Each of the explanations which have been given is 
open to some objection. It is far from unlikely that the intermittent 
contractions of the uterine fibres, which are known to occur during the 
whole course of pregnancy, may have much to do with it, by modifying 
at intervals the rapidity of the circulation in the vessels. Its produc- 
tion in this manner may also be favored by the chlorotic state of the 
blood, to which Cazeaux and Scanzoni are inclined to attribute an im- 
portant influence, likening it to the anaemic murmur so frequently heard 
in the vessels in weakly women. 

From a diagnostic point of view the uterine souffle is of very second- 
ary importance, because a similar sound is very generally audible in 
large fibroid tumors of the uterus, and even in some few ovarian tumors ;. 
it is, therefore, of little or no value in assisting us to decide the charac- 
ter of the abdominal enlargement. The supposed dependence of the 
sound on the placental circulation has caused its site to be often identi- 
fied with that of the placenta. It is, however, most frequently heard at 
the lower part of the uterus, while the placenta is generally attached 
near the fundus, so that its position cannot be taken as any safe guide 
in determining the situation of that organ. 

Occasionally, in practising auscultation irregular sounds of brief dura- 
tion may be heard which are not susceptible of accurate description, and 
which doubtless depend on the sudden movement of the foetus in the 
liquor amnii or on the impact of its limbs on the uterine walls. When 
heard distinctly they are characteristic of pregnancy, and they may be 
sometimes heard when the other sounds cannot be detected. They are, 
however, so irregular and so often entirely absent that they can hardly 
be looked upon in any other light than as occasional phenomena. 

Two other sounds have been described as being sometimes audible, 
which may be mentioned as matters of interest, but which are of no 
diagnostic value. One is a rustling sound, said by Stoltz to be audible 
in cases in which the foetus is dead, and which he refers to gaseous 
decomposition of the liquor amnii ; its existence is, however, extremely 
problematical. The other is a sound heard after the birth of the child, 
and referred by Caillant to the separation of the placental adhesions. 
He describes it as a series of rapid, short scratching sounds, similar to 
those produced by drawing the nails across the seat of a horsehair sofa. 
Simpson ' admitted the existence of the sound, but believed that it is 
produced by the mere physical crushing of the placenta, and artificially 
imitated it out of the body by forcing the placenta through an aperture 
the size of the os uteri. 

It will be seen, then, that although there are numerous signs and 
symptoms accompanying pregnancy, many of them are unreliable by 

^ Selected Obstet. Works, p. 151. 



DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 161 

themselves, and apt to mislead. Those which may be confidently 
depended on are tlie pulsations of the fVjetal heart, which, however, 
fail us in cases of dead children ; the fcjetal movements, when distinctly 
made out ; ballottement ; the intermittent contractions of the uterus ; and 
to these we may safely add the presence of milk in the breasts, provided 
we have to do with a first pregnancy. 

The remainder are of importance in leading us to suspect pregnancy 
and in corroborating and strengtliening other symptoms, but they do 
not, of themselves, justify a positive diagnosis. 



CHAPTER V. 

THE DIFFEKENTIAL DIAGNOSIS OF PKEGNANCY.— SPUEIOUS PKEG- 
NANCY.— THE DUKATION OF PREGNANCY.— SIGNS OF RECENT 
PREGNANCY. 

The differential diagnosis of pregnancy has of late years assumed 
much importance on account of the advance of abdominal surgery. 
The cases are so numerous in which even the most experienced jDrac- 
titioners have fallen into error, and in which the abdomen has been laid 
open in ignorance of the fact that pregnancy existed, that the subject 
becomes one of the greatest consequence. Fortunately, it is less so from 
an obstetrical than from a gynecological point of view, inasmuch as the 
converse error, of mistaking some other condition for pregnancy, is of 
far less consequence, as it is one which time will always rectifv. But 
even in this way carelessness may lead to very serious injury to the 
character, if not to the health, of the patient ; and it will be Avell to refer 
briefly to some of the conditions most liable to be mistaken for preg- 
nancy, and to the mode of distinguishing them. 

Adipose enlargement of the abdomen may obscure the diagnosis by 
preventing tlie detection of the uterus ; and if, as is not uncommon with 
women of great obesity, it is associated with irregular menstruation, the 
increased size of the abdomen might be supposed to depend on preg- 
nancy. The absence of corroborative signs, such as auscultatory phe- 
nomena, mannnary changes, and the hardness of the cervix as felt per 
vaginam, make it easy to avoid this error. 

Distension of the uterus by retained menstrual fluid or watery secre- 
tions is an occurrence of rarity that could seldoi\i give rise to error. 
Still, it occasionally ha])pens that the uterus becomes enlarged in this 
way, sometimes reaching even to the level of the umbilicus, and that the 
physical character of the tumor is not unlike that of the gravid uterus. 
The best safeguard against mistakes will be the previous historv ot' the 
case, which will always be dltl'erent from that of i>rilinarv pregnanev. 
Retention of the menses alihost always occurs from some physical obstruc- 
tion to the exit of the fluid, such as imperforate hymen: or it* it occur 
in women who have already menstruated, we may usuallv trace a his- 
11 



162 PEEGXANCY. 

toiy of some cause, such as inflammation following an antecedent labor, 
which has produced occlusion of some part of the genital tract. The 
existence of a pelvic tumor in a girl who has never menstruated will of 
itself give rise to suspicion, as pregnancy under such circumstances is of 
extreme rarity. It will also be found that general symptoms have 
existed for a period of time considerably longer than the supposed dura- 
tion of pregnancy, as judged of by the size of tlie tumor. The most 
characteristic of them are periodic attacks of pain due to the addition, 
at each monthly period, to the quantity of retained menstrual fluid. 
AYhenever, from any of these reasons, suspicion of the true character of 
the case has arisen, a careful vaginal examination will generally clear it 
np. In most cases the obstruction will be in the vagina, and is at once 
detected, the vaginal canal above it, as felt^er rectum, being greatly dis- 
tended by fluid ; and we may also find the bulging and imperforate 
hymen protruding through the vulva. The absence of mammary 
changes and of ballottement will materially aid us in forming a 
diagnosis. 

The engorged and enlarged uterus frequently met with in women suf- 
fering from uterine disease might readily be taken for an early preg- 
nancy if it happened to be associated with amenorrhoea. A little time 
w^ould, of course, soon clear up the point by showing that progressive 
increase in size, as in pregnancy, does not take place. This mistake 
could only be made at an early stage of pregnancy, when a positive 
diagnosis is never possible. The accompanying symptoms — pain, 
inability to walk, and tenderness of the uterus on pressure — would 
prevent such an error. 

Ascites, per se, could hardly be mistaken for pregnancy, for the uni- 
form distension and evident fluctuation, the absence of any definite 
tumor, the site of resonance on percussion changing in accordance with 
alteration of the position of the woman, and the unchanged cervix and 
uterus, should be suflicient to clear up any doubt. Pregnancy may, 
however, exist with ascites, and this combination may be difficult to 
detect, and might readily be mistaken for ovarian disease associated with 
ascites. The existence of mammary changes, the presence of the soft- 
ened cervix, ballottement, and auscultation — provided the sounds were 
not masked by the surrounding fluid — would affbrd the best means of 
diagnosing such a case. 

One of the most frequent sources of difficulty is the differential diag- 
nosis of large abdominal tumors, either fibroid or ovarian, or of some 
•enlargements due to malignant disease of the peritoneum or abdominal 
viscera. The most experienced have been occasionally deceived under 
such circumstances. As a rule, the presence of menstruation will pre- 
vent error, as this generally continues in ovarian disease, while in 
iibroids it is often excessive. The character of the tumor — the fluc- 
tuation in ovarian disease, the hard nodular masses in fibroid — and the 
Li story of the case, especially the length of time the tumor has existed, 
wall aid in diagnosis, while the absence of cervical softening (vide p. 141) 
and of auscultatory phenomena will further be of material value in 
forming a conclusion. Some of the most difficult cases to diagnose 
are those in which pregnancy complicates ovarian or fibroid disease. 



DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 163 

Then the tumor may more or less completely obscure the })hysical signs 
of pregnancy. The usual shape of the abdomen will generally be 
altered considerably, and we may be able to distinguish the gravid 
uterus, separated from the ovarian tumor by a distinct sulcus or with 
the fibroid masses cropping out from its surface. Our chief reliance 
must then be placed in the alteration of the cervix and in the auscul- 
tatory signs of pregnancy. 

Spurious Preg-nancy. — The condition most likely to give rise to 
errors is that very interesting and peculiar state known as Hpurious 
pregnancy. In this most of the usual phenomena of ])regnancy are 
so strangely simulated that accurate diagnosis is often far from easy. 
There are hardly any of the more apparent symptoms of pregnancy 
which may not be present in marked cases of this kind. The abdomen 
may become prominent, the areolae altered, menstruation arrested, and 
apparent foetal motions felt, and, unless suspicion is aroused and a care- 
ful physical examination made, both the patient and the practitioner niay 
easily be deceived. 

There is no period of the childbearing life in which spurious l)reg- 
nancy may not be met with; but it is most likely to occur in elderly 
women about the climacteric period, when it is generally associated with 
ovarian irritation connected with the change of life ; or in younger 
women who are either very desirous of finding themselves pregnant, 
or who, being unmarried, have subjected themselves to the chance of 
being so. In all cases the mental faculties have nuich to do with its 
production, and there is generally either very marked hysteria or even 
a condition closely allied to insanity. Spurious pregnancy is by no 
means confined to the human race. It is well known to occur in many 
of the lower animals. Harvey related instances in bitches, either after 
unsuccessful intercourse or in connection with their being in heat, even 
when no intercourse had occurred. In such cases the abdomen swelled 
and milk ap])eared in the mammae. Similar phenomena are also 
occasionally met with in the cow. In these instances, as in the 
human female, there is probably some morbid irritation of the 
ovarian system. 

The i)hysical phenomena are often veiy well marked. The apjxir- 
ent enlargement is sometimes very great, and it seems to be produced bv 
a projection forward of the abdominal contents, due to depression of the 
diaphragm, together with rigidity of the abdominal nuiscles, and mav 
even closely sinuilate the uterine tumor on palpation. After the climac- 
teric it is frequently associated, as Gooch pointed out, with an undue 
deposit of fat in the abdominal walls and omentum, so that there mav 
be even some dulness on percussion instead of resonance o\' the intestines. 
The feotal movements are curiously and exactly sinndated, either bv in- 
voluntary contractions of the abdominal widls or by the movement of 
flatus in the intestines. The })atient also generally fancies that she suf- 
fers from the usual sympathetic disorders of prciinancy, and thus lier 
account of her symptoms will still further tend to mislead. 

^ot only may the su|Sposed pregnancy continui\ but at what would 
be the natural term of deli very all the phenomena ot' labor mav sujhm'- 
vene. INIanv authentic cases are on record in which ivi^ular pains came 



164 PREGNANCY. 

on, and coDtinued to increase in force and frequency until the actual con- 
dition Avas diagnosed. Such mistakes, however, are only likely to happen 
Avhen the statements of the patient have been received without further 
inquiry. AVhen once an accurate examination has been made error is no 
longer possible. 

We shall generally find that some of the phenomena of pregnancy are 
absent. Possibly, menstruation, more or less irregular, may have con- 
tinued. Examination per vaginam will at once clear up the case by 
showing that the uterus is not enlarged and that the cervix is unaltered. 
It may then be very difficult to convince the patient or her friends that 
her symptoms have misled her, and for this purpose the inhalation of 
chloroform is of great value. As consciousness is abolished the semi- 
voluntary projection of the abdominal muscles is prevented, the large 
apparent tumor vanishes, and the bystanders can be readily con- 
vinced that none exists. As the patient recovers the tumor again 
appears. 

Duration of Pregnancy. — The duration of pregnancy in the human 
female has always formed a fruitful theme for discussion amongst obste- 
tricians. The reasons which render the point difficult of decision are 
obvious. As the large majority of cases occur in married women, in 
whom intercourse occurs frequently, there is no means of knowing the 
precise period at which conception took place. The only datum which 
exists for the calculation of the probable date of delivery is the cessation 
of menstruation. It is quite possible, however, and indeed probable, 
that conception occurred in a considerable number of instances not im- 
mediately after the last period, but immediately before the proper epoch 
for the occurrence of the next. Hence, as the interval between the end 
of one menstruation and the commencement of the next averages twenty- 
five days, an error to that extent is always possible. Another source of 
fallacy is the fact, which has generally been overlooked, that even a sin- 
gle coitus does not fix the date of conception, but only that of insemi- 
nation. It is well known that in many of the lower animals the 
fertilization of the ovule does not take place until several days after 
copulation, the spermatozoa remaining in the interval in a state of active 
vitality within the genital tract. It has been shown by Marion Sims 
that living spermatozoa exist in the cervical canal in the human female 
some days after intercourse. It is very probable, therefore, that in the 
human female, as in the lower animals, a considerable but unknown in- 
terval occurs between insemination and actual impregnation, which may 
render calculations as to the precise duration of pregnancy altogether 
unreliable. 

A large mass of statistical observations exist respecting the average 
duration of gestation which have been drawn np and collated from 
numerous sources. It would serve no practical ])urpose to reprint the 
voluminous tables on this subject that are contained in obstetrical works. 
They are based on two principal methods of calculation : First, we have 
the length of time between the cessation of menstruation and delivery. 
This is found to vary very considerably, but the largest percentage of de- 
liveries occurs between the 274th and 280th day after the cessation of men- 
struation, the average day being the 278th ; but in individual instances 



DIFFERENTIAL DIAGNOSIS OF PREGNANCY. Ifjo 

very considerable variations both above and below these limits are found 
to exist. Next, we have a series of cases, from various sources, in which 
only one coitus was believed to have taken place. These are naturally 
open to some doubt, but, on the whole, they may be taken as affording 
tolerably fair grounds for calculation. Here, as in the other mode of 
calculation, there are marked variations, the average length of time, 
as estimated from a considerable collection of cases, being 275 days 
after the single intercourse. It may therefore be taken as certain that 
there is no definite time which we can calculate on as being the 
proper duration of pregnancy, and consequently no method of esti- 
mating the probable date of delivery on which we can absolutely 
rely. 

Methods of Predicting* the Probable Date of Delivery. — The 
prediction of the time at which the confinement may be expected is, 
however, a point of considerable practical importance, and one on which 
the medical attendant is always consulted. Various methods of making 
the calculation have been recommended. It has been customary in this 
country, according to the recommendation of Montgomery, to fix upon 
ten lunar months, or 280 days, as the probable period of gestation, and, 
as conception is supposed to occur shortly after the cessation of menstru- 
ation, to add this number of days to any day within the first week after 
the last menstrual period as the most probable period of delivery. As, 
however, 278 days is found to be the average duration of gestation after 
the cessation of menstruation, and as the method makes the calculation 
vary from 281 to 287 days, it is evidently liable to fix too late a date. 
Naegele's method was to count seven days from the first appearance of 
the last menstrual period, and then reckon backward three months as the 
probable date. Thus, if a patient last commenced to menstruate on 
August 10, counting in this way from August 17 would give May 17 
as the probable date of the delivery. 

Matthews Duncan has paid more attention than any one else to the 
prediction of tlie date of delivery. His method of calculating is based 
on the fact of 278 days being the average time between the cessation of 
menstruation and parturition ; and he claims to have had a greater 
average of success in his predictions than on any other plan. His rule 
is as follows : '^ Find the day on which the female ceased to menstruate, 
or the first day of being what she calls ^ well.^ Take that day nine months 
forward as 275 — unless February is included, in which case it is taken 
as 273 — days. To this add three days in the former case, or five if 
February is in the count, to make up the 278. This 278th dav should 
then be fixed on as the middle of the week, or, to make the j>rt\liotion 
tlie more accurate, of the fortnight, in which the confinement is likelv 
to occur, by which means allowance is made for the average variation 
of either excess or deficiency." 

Various periodoscopes and tables for facilitating the calculation have 
been made. The periodosco])e of Dr. Tyler Smith is very usotul t*or 
reference in the consulting-room, giving at a ghuuv a variety o^ intor- 
mation, such as the probable period o^ quickening, the dates tor the 
induction of premature labor, etc. The following table, pivparixi by 
Dr. Protheroe Smith, is also easilv read and is verv serviceable : 



166 PREGNANCY. 

Table foe Calculating the Period of Utero-Gestation.* 





Nine 


Calendar Months. 




, 


Ten Lunar Months. 


From 


To 


Days. 


To 


Days. 


January 




September 


80 


273 


1 

1 October 7 


280 


February 




October 


31 


273 


' November 7 


280 


March 




November 


30 


275 


December 5 


280 


April 




December 


31 


275 


January 5 


280 


May 




January 


31 


276 


J'ebruary 4 


280 


June 




February 


28 


273 


March 7 


280 


July 


I 


March 


31 


274 


April 6 


280 


August 




April 


30 


273 


Mav 7 


280 


September 




May 


31 


273 


June 7 


280 


October 




June 


30 


273 


July 7 


280 


November 




July 


31 


273 


; August 7 


280 


December 




August 


31 


274 


i September 6 


280 



The date at which the quickening has been perceived is relied on by 
many practitioners, and still more by patients, in calculating the proba- 
ble date of delivery, as it is generally supposed to occur at the middle 
of pregnancy. The great variations, however, of the time at which 
this phenomenon is first perceived, and the difficulty which is so often 
experienced of ascertaining its presence with any certainty, render it a 
very fallacious guide. The only times at which the perception of 
quickening is likely to prove of any real value are when impregnation 
has occurred during lactation (when menstruation is normally absent), 
or when menstruation is so uncertain and irregular that the date of its 
last appearance cannot be ascertained. As quickening is most com- 
monly felt diiring the fourth month — more frequently in its first than 
in its last fortnight — it may thus afford the only guide we can obtain, 
and that an uncertain one, for predicting the date of delivery. 

Is Protraction of Gestation Possible ? — From a medico-legal 
point of view the question of the possible protraction of pregnancy 
beyond the average time, and of the limits within which such protrac- 
tion can be admitted, is of very great importance. The law on this 
point varies considerably in different countries. Thus in France it 
is laid down that legitimacy cannot be contested until 300 days have 
elapsed from the death of the husband or the latest possible op]Jortu- 
nity for sexual intercourse. This limit is also adopted by Austria, 
while in Prussia it is fixed at 302 days. In England and America no 
fixed date is admitted, but while 280 days is admitted as the '^ legiti- 
mum tem]->us pariendi,'^ each casein which legitimacy is questioned is to 
be decided on its own merits. At the early part of the century t\\Q 
question was much discussed by the leading obstetricians in connection 

^ The above obstetric " Ready Reckoner " consists of t\vo columns, one of calendar, the 
other of lunar months, and maybe read as follows: A patient has ceased to men- 
struate on July 1 : her confinement maybe expected at soonest about March 31 [the 
end of nine calendar months), or at latest on April 6 (the end of ten lunar months). 
Another has ceased to menstruate on January 20 ; lier confinement may be expected 
on September 30. plus 20 days {the end of nine calendar months), at soonest, or on October 
7, plus 20 days {the end of ten lunar months), at latest. 



DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 167 

with the celebrated Gardner peerage case^ and a considerable diiference 
of opinion existed among them. Since that time many apparently per- 
fectly reliable cases have been recorded in which the duration of gesta- 
tion was obviously much beyond the average, and in which all sources 
of fallacy were carefully excluded. 

Not to burden these pages with a number of cases, it may suffice to 
refer, as examples of protraction, to four well-known instances recorded 
by Simpson,^ in which the pregnancy extended respectively to 336, 332, 
319, and 324 days after the cessation of the last menstrual period. In 
these, as in all cases of protracted gestation, there is the possible source 
of error that impregnation may have occurred just before the expected 
advent of the next period. Making an allowance of 23 days in each 
instance for this, we even then have a number of days much above the 
average — viz. 313, 309, 296, and 301. Numerous instances as curious 
may be found scattered through obstetric literature. Indeed, the expe- 
rience of most accoucheurs will parallel such cases, which may be more 
common than is generally supposed, inasmuch as they are only likely to 
attract attention when the husband has been separated from the wife 
beyond the average and expected duration of the pregnancy. 

The evidence in favor of the possible prolongation of gestation is 
greatly strengthened by what is know^n to occur in the lower animals. 
In some of these, as in the cow and the mare, the precise period of 
insemination is known to a certainty, as only a single coitus is permit- 
ted. Many tables of this kind have been constructed, and it has been 
shown that there is in them a very considerable variation. In some 
cases in the cow it has been found that delivery took place 45 days, and 
in the mare 43 days, after the calculated date. Analogy would go 
strongly to show that what is known to a certainty to occur in the lower 
animals may also take place in the human female. The fact, indeed, is 
now very generally admitted ; but we are still unable to fix with any 
degree of precision on the exti'eme limit to which protraction is pos- 
sible. Some practitioners have given cases in which, on data which they 
believe to be satisfactory, pregnancy has been extremely protracted ; 
thus, Meigs and Adler record instances which they believed to have 
been prolonged to over a year in one case and over fourteen months 
in the other. These are, however, so problematical that little weight 
can be attached to them. On the whole, it would hardly be safe to 
conclude that pregnancy can go more than three or four weeks beyond 
the average time. This conclusion is justified by the cases we possess 
in which pregnancy followed a single coitus, the lono-cst of which Avas 
295 days. 

Dr. Duncan ^ is inclined to refuse credence to every case (~>f supposed 
protraction unless the size and weight of the child are above the aver- 
age, believing that lengthened gestation must of necessity cause increaseil 
growth of the child. This point re(|uires further investigation, and it 
cannot be taken as j>roved that \W tuMus necessarily nuist bo lar^e 
because it has been retaininl longer than usual in ufcro ; or, even it' this 
be admitted, it may have* Ihhmi originally small, and so at the cud of 
the protracted gestation be little above the average weight. There are, 

^ Obatd. Mnnoi'rti, p. 84. ' IWumiitij and FtrtiliU/. p. ;MS. 



168 PREGNANCY. 

however, mauy cases which certainly prove that a prolonged pregnancy 
is at least often associated with an unusually developed foetus. Dr. 
Duncan himself cites several, and a very interesting one is mentioned 
by Leishman, in which delivery took place 295 days after a single 
coitus, the child weighing 12 pounds 3 ounces. 

It seems possible that in some cases of protracted pregnancy labor 
actually came on at the average time, but on account of faulty posi- 
tions of the uterus or other obstructing cause the pains were inef- 
fective and ultimately died away, not recurring for a considerable 
time. Joulin relates some instances of this kind. In one of them 
the labor was expected from the 20th to the 25th of October. He 
w^as summoned on the 23d, and found the pains regular and active, 
but ineffective ; after lasting the whole of the 24th and 25th they 
died away, and delivery did not take place until November 25th, after 
the lapse of a month. In this instance the apparent cause of diffi- 
culty was extreme anterior obliquity of the uterus. A precisely sim- 
ilar case came under my own observation. The lady ceased to men- 
struate on March 16, 1870. On December 12 — that is, on the 273d 
day — strong labor-pains came on, the os dilated to the size of a 
florin, and the membranes became tense and prominent with each 
pain. After lasting all night they gradually died away, and did not 
recur until January 12, 304 days from the cessation of the last period. 
Here there was no assignable cause of obstruction, and the laboi^, when 
it did come on, was natural and easy. 

The curious fact that in both these cases, as in others of the same 
kind that are recorded, labor came on exactly a month after the previous 
ineffectual attempt at its establishment, affords, so far as it goes, an argu- 
ment in favor of the view maintained by many that labor is apt to come 
on at what would have been a menstrual period. 

Signs of Recent Delivery. — From a forensic point of view it often 
becomes of importance to be able to give a reliable opinion as to the fact 
of delivery having occurred, and a few words may be here said as to the 
signs of recent delivery. Our opinion is only likely to be sought in cases 
in which the fact of delivery is denied, and in which we must, therefore, 
entirely rely on the results of a physical examination. If this be under- 
taken within the first fortnight after labor, a positive conclusion can be 
readily arrived at. 

At this time the abdominal walls will still be found loose and flaccid, 
and bearing very evident marks of extreme distension in the cracks and 
fissures of the cutis vera. These remain permanent for the rest of the 
patient's life, and may be safely assumed to be signs of an antecedent 
pregnancy, provided we can be certain that no other cause of extreme 
abdominal distension has existed, such as ascites or ovarian tumor. 

AYithin the first few days after delivery the hard round ball formed 
by the contracted and empty uterus can easily be felt by abdominal pal- 
pation, and more certainly by combined external and internal examina- 
tion. The process of involution, however, by which the uterus is 
reduced to its normal size, is so rapid that after the first week it can no 
longer be made out above the brim of the pelvis. In cases in which an 
accurate diagnosis is of importance the increased length of the uterus can 



DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 169 

be ascertained by the uterine sound, and its cavity will measure more 
than the normal 2| inches for at least a month after delivery. It 
should not be forgotten that the uterine parietes are now undergoing 
fatty degeneration, and that they are more than usually soft and friable, 
so that the sound should be used with great caution and only when a 
positive opinion is essential. The state of the cervix and of the vagina 
may afford useful information. Immediately after delivery the cervix 
hangs loose and patulous in the vagina, but it rapidly contracts, and the 
internal os is generally entirely closed after the eighth or tenth day. 
The remainder of the cervix is longer in returning to its normal shape 
and consistency. It is generally permanently altered after delivery, the 
external os remaining fissured and transverse, instead of circular Avith 
smooth margins as in virgins. The vagina is at first lax, swollen, and 
dilated, but these signs rapidly disappear, and cannot be satisfactorily 
made out after the first few days. The absence of the fourchette may 
be recognized, and is a persistent sign. 

The presence of the lochia affords a valuable sign of recent delivery. 
For the first few days they are sanguineous, and contain numerous 
blood-corpuscles, epithelial scales, and the debris of the decidua. After 
the fifth day they generally change in color, and become pale and green- 
ish, and from the eighth or ninth day till about a month after delivery 
they have the appearance of thick opalescent mucus. They have, how- 
ever, a peculiar, heavy, sickening odor, which should prevent their being 
mistaken for either menstruation or leucorrhoeal discharge. 

The appearance of the breasts will also aid the decision, for it is 
impossible for the patient to conceal the turgid, sw^ollen condition of 
the mammae, with the darkened areola, and, al)ove all, the presence of 
milk. If, on microscopic examination, the milk is found to contain 
colostrum-corpuscles, the fact of very recent delivery is certain. In 
women who do not nurse it should be remembered that the secretion of 
milk often rapidly disappears, so that its absence cannot be taken as a 
sign that delivery has not taken place. On the whole, there should be 
no difficulty in deciding that a woman has been delivered, as some of 
the signs are persistent for the rest of her life ; but it is not so easy, 
unless we see the case within the first eight or ten days, to say how long 
it is since labor took place. 



170 



PREGNANCY. 



CHAPTEE YI. 

ABNORMAL PEEGXAXCY, INCLUDING MULTIPLE PREGNANCY, 
SUPER FCETATION, EXTRA-UTERINE FCETATION, AND MISSED 
LABOR. 

The occurrence of more than one foetus in utero is far from uncom- 
mon, but there are cuTumstances connected with it which justify the 
conchision that phn-al births must not be classified as natural forms of 
pregnancy. The reasons for this statement have been well collected by 
Dr. Arthur Mitchell/ wlio conclusively shows that not only is there a 
direct increase of risk both to the mother and her offspring, but that 
many abnormalities, such as idiocy, imbecility, and bodily deformity,, 
occur Avith much greater frequency in twins than in single-born chil- 
dren. He concludes that " the whole history of twin births is excep- 
tional, indicates imperfect development and feeble organization in the 
product, and leads us to regard twinning in the human species as a 
departure from the physiological rule, and therefore injurious to all 
concerned.^' 

The frequency of multiple births varies considerably under differ- 
ent circumstances. Taking the average of a large number of cases collected 
by authors in various countries, Ave find that twin pregnancies occur 
about once in 87 labors ; triplets, once in 7679. A certain number of 
quadruple pregnancies, and some cases of early abortion in which there 
were five foetuses, are recorded, so that there can be no doubt of the pos- 
sibility of such occurrences ; l)ut they are so extremely uncommon that 
they may be looked upon as rare exceptions, the relative frequency of 
which can hardly be determined. 

The frequency of multiple pregnancy varies remarkably in different 
races and countries. The following table ^ u'ill show this at a glance : 



Relative Frequency of Multiple Pregnancies in Europe. 



Countries. 


Proportion of 

Twin to Single 

Births. 


Proportion of 
Triplets. 


Proportion of 
Quadruplets. 


England 

Austria 

Grand Duchy of Baden . . 

Scotland . ' 

France 

Ireland 

Mecklenburg-Sclnverin . . 
Norway 


1 : 116 
1 : 94 
1 : 89 
1 : 95 
1 : 99 
1 : 64 
1 : 68.9 
1 : 81.62 
1 : 89 
1 : 50.05 
1 : 79 
1:102 
1: 862 


1 : 6720 

1 : 6575 

1 : 8256 
1 : 4995 
1 : 6436 
1 : 5442 


1 : 2,074,306 
1: 167,226 
1 : 183,236 


Prussia . 

Russia 

Saxony 

Switzerland 

Wiirtemberg 


1 : 7820 
1 : 4054 
1 : 1000 

1 : 6464 


1 : 394,690 
1 : 400,000 
1 : 110,991 



» Med. Times and Gaz., Nov., 1862. 



' Puech, Des Naissances multiples. 



ABNORMAL PREGNANCY. 171 

It will be seen that the largest proportion of multiple births occurs in 
Russia, and that the number of triple births is greatest where twin 
pregnancies are most frequent. Puech concludes that the number of 
multiple pregnancies is in direct proportion to the general fecundity of 
the inhabitants. 

Dr. Duncan has deduced some interesting laws with regard to the 
production of twins from a large number of statistical observa- 
tions ; ^ especially that the tendency to the production of twins in- 
creases as the age of tlie woman advances, and is greater in each 
succeeding pregnancy, exception being made for the first pregnancy, 
in which it is greater than in any other. Newly-married women 
appear more likely to have twins the older they are. There can be no 
doubt that there is often a strong hereditary tendency in individual 
fiimilies to multiple births. A remarkable instance of this kind is 
recorded by Mr. Curgenven,^ in which a woman had four twin preg- 
nancies, her mother and aunt each one, and her grandmother two. 
Simpson mentions a case of quadruplets, consisting of three males and 
one female, who all survived, the female subsequently giving birth to 
triplets.^ 

Sex of Children. — In the largest number of cases of twins the chil- 
dren are of opposite sexes, next most frequently there are two females, 
and twin males are the most uncommon. Thus, out of 59,178 labors, 
Simpson calculates that twin male and female occurred once in 199 
labors, twin females once in 226, and twin males once in 258. The 
proportion of male to female births is also notably less in twin than 
in single pregnancies. 

Size of Foetuses. — Twins, and a fortiori triplets, are almost always 
smaller and less perfectly developed than single children. Hence the 
chances of their survival are much less, and Clarke calculates the 
mortality amongst twin children as 1 out of 13. Of triplets, indeed, 
it is comparatively rare that all survive, while in quadruplets premature 
labor and the death of the foetuses are almost certain. It is a common 
observation that twins are often unequally developed at birth. By some 
tliis diiference is attributed to one of them being of a ditierent age to 
the other. It is probable, however, that in most of these cases the full 
development of one foetus has been interfered with by pressure of the 
other. This is far from uncommonly carried to the extent of destroy- 
ing one of the twins, which is expelled at term nuunmified and 
flattened between the living child and the uterine wall. In other 
cases, when tlie fa^tus dies it may be expelled without terminating 
.the pregnancy, the other being retained in ufo'o and born at term : 
and those who disbelieve in the possibility of superfivtation explain in 
this way the cases in which it is Ix^lieved to have (H'cui-rod. 

Multiple pregnancies depend on various causes. The nmst eoinmon 
is probably the sinudtaneous or ni^u'ly sinudtaneous maturation and 
ruj)ture of two (Iraalian follicles, the ovules becoming impregnated at 
or about the same time. It by no means necessarilv tbllows, even if 
more than one follicle slioidd riii)t.tn'e at once, that both ovules should 

^ On Fecunditi/, Ferdlilii, ixud S(<rilHu, p. 99. 

2 Obst. Trans.] 1870, \o\. xi. p. \(h\.' ^ Obst. Works, p. S;.0. 



172 PREGNANCY. 

be impregnated. This is proved by tlie occurrence of cases in which 
there are two corpora hitea with only one foetus. There are numerous 
facts to prove that ovules thrown olf within a short time of each other 
may become separately impregnated, as in cases in which negro women 
have given birth to twins, one of which was pure negro, the other half- 
caste. 

It may happen, however, that a single Graafian follicle contains more 
than one ovule, as has actually been observed before its rupture ; or, as 
is not uncommon in the egg of the fowl, an ovule may contain a double 
germ, each of which may give rise to a separate foetus. 

Arrang-ement of the Foetal Membranes and Placentee. — The 
various modes in which twins may originate explain satisfactorily the 
variations which are met with in the arrangement of the foetal mem- 
branes and in the form and connections of the placentae. In a large 
proportion of cases there are two distinct bags of membranes, the sep- 
tum between them being composed of four layers — viz. the chorion and 
amnion of each ovum. The placentse are also entirely separate. Here 
it is obvious that each twin is developed from a distinct ovum, having 
its own chorion and amnion. On arriving in the uterus it is prob- 
able that each ovum becomes fixed independently in the mucous 
membrane and is surrounded by its own decidua reflexa. As growth 
advances the decidua reflexa generally atrophies from pressure, as 
it is not usual to find more than four layers of membrane in the 
septum separating the ova. In other cases there is only one chorion, 
within which are two distinct amnions, the septum then consisting 
of two layers only. Then the placentae are generally in close appo- 
sition and become fused into a single mass, the cords, separately 
attached to each foetus, not infrequently uniting shortly before reaching 
the placental mass, their vessels anastomosing freely. In other more 
rare instances both foetuses are contained in a common amniotic sac; 
but as the amnion is a purely foetal membrane, it is probable that when 
this arrangement is met with the originally existing septum between 
the amniotic sacs has been destroyed. In both these latter cases the 
twdns must have been developed from a single ovule containing a 
double germ, and Schroeder states that they are then always of the 
same sex. Dr. Brunton ^ has started a precisely opposite theory, and 
has tried to prove that twins of the same sex are contained in separate 
bags of membrane, while tw^ins of opposite sexes have a common sac. 
He says that out of 25 cases coming under his observation, in 1 5 the 
children contained in different sacs were of the same sex, but in the 
remaining 10, in which there was only one sac, they were of opposite 
sexes. It is difficult to believe that there is not an error in these 
observations, since twins contained in a single amniotic sac do not occur 
nearly as often as ten times out of twenty-five cases, and no distinction 
is made between a common chorion with two amnions and a single 
chorion and amnion. The facts of double monstrosity also disprove 
this view^, since conjoined twins must of necessity arise from a single 
ovule Vith a double germ, and there is no instance on record in which 
they were of opposite sexes. 

J Ohst. Trans., vol. xi. p. 67. 



ABNORMAL PREGNANCY. 173 

In triplets the membranes and placentae may be all se])arate, or, as is 
commonly the case, there is one complete bag of membranes, and a 
second having a common chorion with a double amnion. It is prob- 
able, therefore, that triplets are generally developed from two ovules, 
one of which contains a double germ. 

Diagnosis of Multiple Preg-nancy. — It is comparatively seldom 
that twin pregnancy can be diagnosed before the birth of the first child, 
and even when suspicion has arisen its indications are very defective. 
There is generally an unusual size and an irregularity of shape of the 
uterus, sometimes even a distinct depression or sulcus between the two 
foetuses. When such a sulcus exists, it may be possible to make out 
parts of each foetus by palpation on either side of the uterus. The only 
sign, however, on which the least reliance can be placed is the detection 
of two foetal hearts. If two distinct pulsations are heard at different 
parts of the uterus ; if on carrying the stethoscope from one point to 
another there is an interspace where pulsations are no longer audible, or 
when they become feeble and again increase in clearness as the second 
point is reached; and, above all, if we are able to make out a difference 
in frequency between them, — the diagnosis is tolerably safe. It must be 
remembered, however, that the sounds of a single heart may be heard 
over a larger space than usual, and hence a possible source of error. 
Twin pregnancy, moreover, may readily exist without the most careful 
auscultation enabling us to detect a double pulsation, especially if one 
child lie in the dorso-posterior position, when the body of the other 
may prevent the transmission of its heart's beat. The so-called 
placental souffle is generally too diffuse and irregular to be of any 
use in diagnosis, even when it is distinctly heard at separate parts 
of the uterus. 

Superfoetation and Superfecundation. — Closely connected with 
the subject of multiple pregnancies are the conditions known as super- 
fecundation and superfoetation^ regarding which there have been much 
controversy and difference of opinion. 

By the former is meant the fecundation, at or near the same period 
of time, of two separate ovules before the decidua lining the uterus has 
been formed, which by many is supposed to form an insuperable obsta- 
cle to subsequent impregnation. The possibility of this occurrence has 
been incontestably proved by the class of cases already referred to, in 
which the same woman has given birth to twins bearing evident traces 
of being the offsj)ring of fathers of different ra('(\^. 

By superf<rt(ttio)i is meant the impregnation of a second ovule when 
the uterus already contains an ovum which has arrived at a considerable 
degree of development. The cases which are supposed to prove the 
possibility of this occurrence are very numerous. They are those in 
which a woman is delivered simultaneously of foetuses of very ditferont 
ag(\s, one bearing all the marks of having arrived at term, the other o{ 
})rematurity ; or those in which a woman is delivered oi' an apparenily 
mature child, and, after the laj)se of a few nuuuhs, ot' another iH]ually 
mature. The possibility of superlactation is strongly denietl by many 
practitioners of eminence, and explanations are given which doubiless 
seem to account satisfactorily for a large propi>rtiiMi of the supposed 



174 PEEGXANCY. 

examples. lu tlie former class of cases it is supposed, with much 
probability, that there is an ordinary t^yin pregnancy, the development 
of one foetus being retarded by the presence in utero of another. That 
this is not. an uncommon occurrence is certain, and the fact has already 
been alluded to in treating of twin pregnancy. In cases of the latter 
kind it is possible that some of them may be due to separate impregna- 
tion in a bilobed uterus, the contents of one division being thrown off a 
considerable time before those of the other. Numerous authentic exam- 
ples of this occurrence are recorded, but by far the most remarkable is 
that related by Dr. Ross of Brighton, which has been already referred 
to (p. 6S). In this case the patient had previously given birth to many 
children without any suspicion of her abnormal formation having arisen, 
and, had it not been detected by Dr. Ross, the case might fairly enough 
have been claimed as an indubitable example of superfoetation. 

Making every allowance for these explanations, there remains a con- 
siderable number of cases which it is very difficult to account for except 
on the supposition that the second child has been conceived a consider- 
able time after the first. Those interested in the subject will find a 
large number of examples collected in a valuable paper by Dr. Bonnar 
of Cupar.^ He has adopted the ingenious plan of consulting the records 
of the British peerage, where the exact date of the birth of successive 
children of peers is given, without, of course, any reasonable possibilit}^ 
of error, and he has collected numerous examples of births rapidly suc- 
ceeding each other which are apparently inexplicable on any other 
theory. In one case he cites a child was born September 12, 1849, and 
the mother gave birth to another on January 24, 1850, after an inter- 
val of only 127 days. Subtracting from that 14 days, which Dr. 
Bonnar assumes to be the earliest possible period at which a fresh 
impregnation can occur after delivery, we reduce the gestation to 113 
days ; that is, to less than four calendar months. As both these chil- 
dren survived, the second child could not possibly have been the result 
of a fresh impregnation after the birth of the first ; nor could the first 
child have been a twin prematurely delivered, for if so it must have only 
reached rather more than the fifth month, at which time its survival 
would have been impossible. 

Besides the numerous examples of cases of this kind recorded in most 
obstetric works, there are one or two of miscarriage in the early months, 
in which, in addition to a foetus of four or five months' growth, a per- 
fectly fresh ovum of not more than a month's development was thrown 
off. One such case was shown at the Obstetrical Society in 1862, which 
was reported on by Drs. Harley and Tanner, who stated that in their 
opinion it was an example of superfoetation. A still more conclusive 
case is recorded by Tyler Smith •} " A young married woman, pregnant 
for the first time, miscarried at the end of the fifth month, and some 
hours afterward a small clot was discharged enclosing a perfectly 
healthy ovum of about one month. There were no signs of a double 
uterus in this case. The patient had menstruated regularly during the 
time she had been pregnant." This case is of special interest from the 
fact of the patient having menstruated during pregnancy — a circum- 

1 Edin. Med. Journ., 1864-65. ^ Manual of Obstetrics, p. 112. 



ABNORMAL PREGNANCY. 



175 



stance only explicable on the same anatomical grounds which render 
superfoetation possible. So far as I know, it is the only instance in 
which the coincidence of superfoetation and menstruation during early 
pregnancy has been observed. 

The objections to the possibility of superfoetation are based on the 
assumptions that the decidua so completely fills up the uterine cavity 
that the passage of the spermatozoa is impossible ; that their passage is 
prevented by the mucous plug which blocks up the cervix ; and that 
when impregnation has taken place ovulation is suspended. It is, how- 
ever, certain that none of these is an insuperable obstacle to a second 
impregnation. The first was originally based on the older and errone- 
ous view which considered the decidua to be an exudation lining the 
entire uterine cavity and sealing up the mouths of the Fallopian tubes 
and the aperture of the internal os uteri. The decidua refiexa, however, 
does not come into apposition with the decidua vera until about the 
eighth week of pregnancy, and therefore until that time there is a free 
space between the two membranes through which the spermatozoa might 
pass to the open mouths of the Fallopian tube, and in which a newly- 
impregnated ovule might graft itself. A reference to the accompanying 
figure of a pregnancy in the third month, copied from Coste's work, will 
readily show that, as far as the decidua is concerned, there is no mechan- 

Fm. 81. 




Illustrating the Cavity bctweoii the Doculua \'ern aiul (he Dooiduu Koticxa duriug the earlv 
moullis orprognaiu'v. (Alter Coste.t 



ical obstacle to the descent and lodgment o{' another impreo-natLHl ovule 
(Fig. 81). Then, as regards the }>hig of nuicus, it is pretty certain that 
this is in no way different from the muctis filling the cervix in the noti- 
pregnant state, which otfers no obstacle at all to the [nissaux^ yA' the >per- 



1 76 PREGNANCY. 

matozoa. Lastly, respecting the cessation of ovulation during pregnancy, 
this, no doubt, is the rule, and probably satisfactorily explains the rarity 
of super foetati on. There are, however, a sufficient number of authenti- 
cated cases of menstruation during pregnancy to prove that ovulation 
is not always absolutely in abeyance ; and as long as it occurs there is 
unquestionably no positive mechanical obstruction, at least in the early 
montlis of pregnancy, in the way of the impregnation and lodgment of 
the ovules that are thrown off. The reasonable conclusion, therefore, 
seems to be that, although a large majority of the supposed cases are 
explicable in other ways, it cannot be admitted that superfoetation is 
either physically or mechanically impossible. 

Extra-uterine Pregnancy. — The most important of the abnormal 
varieties of pregnancy, if we consider the serious and very generally 
fatal results attending it, is the so-called extra-uterine fcetation, which 
consists in the arrest and development of the ovum outside the cavity 
of the uterus. Of late years this subject has received much well-merited 
attention, which, it is to be hoped, may lead to the establishment of some 
definite rules for the management of this most anxious and dangerous 
class of cases. 

Site of Extra-uterine Pregnancy. — The ovum may be arrested and 
developed in various situations on its way to the uterus, most commonly 
in some part of the Fallopian tube, or it may be in the cavity of the 
abdomen, or even quite beyond it, as in a few rare cases in which the 
ovum has found its w^ay into a hernial sac. 

Extra-uterine gestation may be subdivided into the following classes : 
1st, and most common of all, tubal gestation, and as varieties of this, 
although by some made into distinct classes, (a) interstitial, (b) tubo-ova- 
rian gestation, and (c) subperitoneo-jjelviG or intra-ligamentous. In the 
first of these subdivisions the ovum is arrested in the part of the Fallo- 
pian tube that is situated in the substance of the uterine parietes ; in the 
second, at or near the fimbriated extremity of the tube, so that part of 
its cyst is formed by the tube and part by the ovary ; in the third, an 
originally tubal pregnancy develops into the broad ligament, and con- 
tinues this development beneath the peritoneum of the pelvic floor. The 
occurrence of this variety has been conclusively demonstrated by Hart 
and Carter.^ 2d. Abdominal gestation, in which an ovum, instead of 
finding its way into the tube, falls into the peritoneal cavity, and there 
becomes attached and developed ; or the so-called secondary abdominal 
gestation, in which an extra-uterine pregnancy, originally tubal, 
becomes ventral through rupture of its cysts and escape of its contents 
into the abdominal cavity ; or in which an intra-ligamentous pregnancy 
continues to develop until it lifts up the abdominal peritoneum and 
forms a purely extra-peritoneal variety of abdominal gestation. This 
has been called by Hart and Carter subperitoneo-abdominal. 3d. Ova- 
rian gestation, the existence of which is denied by many writers of emi- 
nence, such as Velpeau and Arthur Farre, while it is maintained by 
others of equal celebrity, such as Kiwisch, Coste, and Hecker. It must 
be admitted that it is extremely difficult to understand how an ovarian 
pregnancy, in the strict sense of the w^ord, can occur, for it implies that 

^ Sectional uinatomy of Advanced Extra-uterine Gestation, Edin., 1887. 



ABNORMAL PREGNANCY. 177 

the ovule has become impregnated before the laceration of the Graafian 
follicle, through the coats of which the spermatozoa must have passed. 
Coste, indeed, believes that this frequently happens ; but, while sper- 
matozoa have been detected on the surface of the ovary, their penetra- 
tion into the Graafian follicle has never been demonstrated. Farre has 
also clearly shown that in many cases of supposed ovarian pregnancy 
the surrounding structures were so altered that it was impossible to trace 
their exact origin and to say to a certainty that the foetus was really 
within the substance of the ovary. Kiwisch gives a reasonable expla- 
nation of these cases by supposing that sometimes the Graafian follicle 
may rupture, but that the ovule may remain within it without being 
discharged. Through the rent in the walls of the follicle the spermato- 
zoa may reach and impregnate the ovule, which may develop in the situ- 
ation in which it has been detained. The subject has recently been ably 
considered by Puech,^ who admits two varieties of ovarian pregnancy, 
according as the foetus has developed in a vesicle which has remained 
open or in one which has closed immediately after fecundation. He 
considers that most cases of so-called ovarian pregnancy are either der- 
moid cysts, ovario-tubal pregnancies, or abdominal pregnancies in which 
the placenta is attached to the ovary, and that even in the rare cases of 
true ovarian pregnancies the progress and results do not differ from that 
of abdominal pregnancy. While, therefore, it is impossible to deny the 
existence of ovarian pregnancy, it must be considered to be a very rare 
and exceptional variety, the existence of which has never been actually 
proved ; which, as far as treatment and results are concerned, does not 
differ from tubular or abdominal gestation. 4th. There are two rare 
varieties in which an ovum is developed either in the supplementary 
horn of a bilobed uterus or in a hernial sac. 

For the sake of clearness we may place these varieties of extra-ute- 
rine gestation in the following tabular form : 

1st. Tubals 

(a) Insterstitial, (6) Tubo-ovarian, (c) Subperitoueo-pelvic. 

2d. Abdominal — 

(a) Primary, (b) Secondary. 

3d. Ovarian. 

4th. In bilobed iderus, hernial, etc. 

Causes. — The etiology of extra-uterine foetation in any individual 
case must necessarily be almost always obscure. Broadly speaking, it 
may be said that extra-uterine foetation may be produced by any ct^ndi- 
tion which prevents or renders difficult the passage of the ovule to the 
uterus, while it does not prevent the access of the spermatozoa to the 
ovule. Thus, inflammatory thickening of the coats of the Fallopian 
tubes by lessening their calibre, but not sufficiently so as to prevent 
the passage of the spermatozoa, may interfere with the movements oi' 
the tube which propel the ovum forward, j\nd si^ cause its arrest. A 
similar effect may be produced by various morlMcl conditions, such as 
inflammatory adhesions, from old-standing peritonitis, ]nvssing cm\ the 
tube ; obstruction of its calibre by inspissated mucus or small poly- 
poid growths; the pressure of uterine ov oihcv tumors, and the like. 

^ Anal, di- (finur., 1878, toin. x. p. 102. 
12 



178 PBEGXAXCY. 

The fact that extra-nterine pregnancies occur most frequently in mul- 
tiparae, and comparatively rarely in women under thirty years of age, 
tends to sho^Y that these conditions, which are clearly more likely to 
be met with in such women than in young primiparae, have consid- 
erable influence in their causation. A curiously large proportion of 
cases occur in women who have either been previously altogether 
sterile or in whom a long interval of time has elapsed since their 
last pregnancy. The disturbing effects of fright, either during coition 
or a few days afterward, have been insisted on by many authors as 
a possible cause. Numerous cases of this kind are recorded, and, 
although the influence of emotion in the production of this condi- 
tion is not susceptible of proof, it is not difficult to imagine that 
spasms of the Fallopian tubes might be produced in ^his way which 
would either interfere with the passage of the ovum or direct it into 
the abdominal cavity. The occurrence of abdominal pregnancy is 
probably less difficult to account for if we admit, with Coste, that 
the ovule becomes impregnated on the surface of the ovary itself, 
for there must be very many conditions which prevent the proper adap- 
tation of the fimbriated extremity of the tube to the surface of the 
ovary, and, failing this, the ovum must of necessity drop into the 
abdominal cavity. Kiwisch has pointed out that this is particularly 
apt to occur when the Graafian follicle develops on the posterior sur- 
face of the ovary ; and, indeed, it is probable that it may be of com- 
mon occurrence, and that the comparative rarity of abdominal preg- 
nancy is due to the difficulty with which the impregnated ovule 
engrafts itself on the surrounding viscera. Impregnation may act- 
ually occur in the abdominal cavity itself, of which Keller ' relates a 
remarkable instance. In this case Koeberle had removed the body 
of the uterus and part of the cervix, leaving the ovaries. In the 
portion of the cervix that remained there was a fistulous aperture 
opening into the abdominal cavity, through which semen passed and 
produced an abdominal gestation. Several curious cases are also 
recorded, w^hich have given rise to a good deal of discussion, in wliich 
a tubal pregnancy existed while the corpus luteum was on tlie oppo- 
site side (Fig. 82). The most probable explanation, however, is that 
the fimbriated extremity of the tube in which the ovum was found 
had twisted across the abdominal cavity and grasped the opposite 
ovary, in this way perhaps producing a flexion which impeded the 
progress of the ovum it had received into its canal. Tyler Smith 
suggested that such cases might be explained by supposing that the 
ovum, after reaching the uterus, failed to graft itself in the mucous 
membrane, but found its way into the opposite Fallopian tube. Kuss- 
mauP thinks that such a passage of the ovum across the uterine cav- 
ity may be caused by muscular contraction of the uterus occurring 
shortly after conception, squeezing the yet free ovum upward toward 
the opening of the opposite tube, and possibly into the tube itself. 

The history and progress of cases of extra-uterine pregnancy are 
materially different according to their site, and for practical purposes 

^ Des Grossesses extra-uteri nes, Paris, 1872. 
2 J/on./. Geburt., 1862, Bd. xx. S. L'Oo. 



ABNORMAL PREGNANCY. 179 

we may consider them as forming two great classes, the tuljal (witli 
its varieties) and the abdomlnaL 

Tubal Preg-nancies. — ^When the ovum is arrested in any part of 
the Fallopian tube the chorion soon commences to develop villi Just 
as in ordinary pregnancy, vv^hich engraft themselves into the mucous 
lining of the tube and fix the ovum in its new position. The 

Fig. 82. 




Tubal Pregnancy, with the Corpus Luteum in the Ovary of the Opposite Side. 
The decidua is represented in the process of detachment from the uterine cavity. 

mucous membrane becomes hypertrophied, much in the same way as 
that of the uterus under similar circumstances, so that it becomes 
developed into a sort of pseudo-decidua, the uterine extremity of which 
has been observed to be open and in communication with the lining 
membrane of the uterus.^ Inasmuch, however, as the mucous coat 
of the tubes is not furnished with tubular glands, a true decidua can 
scarcely be said to exist ; nor is there any growth of membrane around 
the ovum analogous to the decidua reflexa. The ovum is, therefore, 
comparatively speaking, loosely attached to its abnormal situation, 
and hence hemorrhage from laceration of the chorion villi can very 
readily take place. 

It is seldom that any development of the chorion villi into distinct 
placental structure is observed : this is probably owing to the fact that 
laceration and death generally occur before the period at which the 
placenta is normally formed. The nuiscular coat of the tube soon 
becomes hypertrophied, and as the size of the ovum increases the 
fibres are separated from each other, so that the ovum protrudes at 
certain poiiits through them, and at these it is only covered by the 
stretched and attenuated nuicous and peritoneal coats of the tube. ^Vt 
this time the tubal pregnancy iorins a smooth oval tumor, which, as a 
rule, has not formed any adhesions to the surrounding structures (^Fig. 
83). The part of the tube unoccupied by the ovum may be found un- 
altered, and permeable in both directions, or, more frequently, it beconu^ 
so stretched and altered 'that its canal cannot be detected. Most tVt^ 
quently it is that part of tlu^ tube nearest the uterus which cannot bo 

' L. IkuhH. BiUroiKs Ifaudbiwh ih-r Fi\uuukniu'<lit'i(cn. 



180 



PEEGXAXCY. 



made out. Tlie condition of the uterus in this as in other forms of 
extra-uterine pregnancy has been the subject of considerable discussion. 
It is now universally admitted that the uterus undergoes a certain 
amount of sympathetic engorgement, the cervix becomes softened as in 
natural pregnancy, and the mucous membrane develops into a true 




Tubal Pregnancy. (From a specimen in the Museum of King's College.) 

decidua. In many cases the decidua is found on post-mortem examina- 
tion, in others it is not, and hence the doubts that some have expressed 
as to its existence. The most reasonable explanation of its absence is 
that given by Duguet,^ who has shown that it is far from uncommon for 
the uterine decidua to be thrown off en masse durino; the hemorrhas^ic 
discharges which so frequently precede the fatal issue of extra-uterine 
gestation. 

Interstitial and False Ovarian Pregnancy. — AVhen the ovum is 
arrested in that portion of the tube passing through the uterus in so- 
called interstitial pregnancy, the muscular fibres of the uterus become 
stretched and distended and form the outer covering of the ovum. 
AYhen, on the other hand, the site of arrest is in the fimbriated ex- 
tremity of the tube, the containing cyst is formed partly of the fimbriae 
of the tube, partly of ovarian tissue ; hence it is much more distensible, 
and the pregnancy may continue without laceration to a more advanced 
period, or even to term, so that when the ovum is placed in this situa- 
tion the case much more nearly resembles one of abdominal pregnancy. 

Progress and Termination. — The termination of tubal pregnancy 
in the immense majority of cases is death, produced by laceration giving 
rise either to internal hemorrhage or to subsequent intense peritonitis. 
Rupture usually occurs at an early period of pregnancy, most generally 

^ Annates de Gynecologie, 1874, torn. i. p. 269. 



ABNORMAL PREGNANCY. 181 

from the fourth to the twelflli week, rarely later. However, a few in- 
stances are recorded in which it did not take place until the fourth or 
fifth month, and Saxtor])h an'd Spiegelberg have recorded apparently 
authentic cases in which the pregnancy advanced to term without 
laceration : these were, however, probably examples of the subperi- 
toneo-pelvic or abdominal varieties. It is generally effected by dis- 
tension of the tube, which at last yields at the point which is most 
stretched; and sometimes it seems to })e hastened or determined by 
accidental circumstances, such as a blow or fall or the excitement of 
sexual intercourse. 

Symptoms of Rupture. — The symptoms accompanying rupture are 
those of intense collapse, often associated with severe abdominal pain, 
produced by the laceration of the cyst. The patient will be found 
deadly pale, with a small, thready, and almost imperceptible pulse, 
perhaps vomiting, but with mental faculties clear. If the liemor- 
rhage be considerable she may die without any attempt at reaction. 
Sometimes, however — and this generally occurs in cases in which the 
tube tears, the ovum remaining intact — the hemorrhage may cease on 
account of the ovum protruding through the aperture and acting as a 
])lug. The patient may then imperfectly rally, to be again prostrated 
by a second escape of blood, which proves fatal. If the loss of blood 
is not of itself sufficient to cause death from shock and anaemia, the 
fatal issue is generally only postponed, for the effused blood soon sets 
up a violent general peritonitis, which rapidly carries off the patient. 
If she should survive the second danger, the case is transformed into 
one of abdominal pregnancy, the foetus becoming surrounded by a 
capsule produced by inflammatory exudation (Fig. 84). The case is 
then subjected to the rules of treatment presently to be discussed when 
considering that variety of extra-uterine gestation. 

Diagnosis.— The possibility of diagnosing tubal gestation before 
rupture occurs is a question of great and increasing interest, from 
the fact that could its existence be ascertained we might very fairly 
hope to avert the almost certainly fatal issue which is awaiting the 
patient. Unfortunately, the symptoms of tubal pregnancy are always 
obscure, and too often death occurs without the slightest suspicion as 
to the nature of the case having arisen. In the first place, it is to be 
observed that all the usual sympathetic disturbances of pregnancy exist: 
the breasts enlarge, the areola darken, and morning sickness is present. 
There is also an arrest of menstruation, but after the absence of one 
or more periods there is often an irregular hemorrhagic discharge. This 
is an important symptom, the value of wliich in indicating the existence 
of tubal pregnancy has of late yeai's been nuich dwelt upon bv various 
authors, both in this country and abroad, liarnes attributes it to partial 
detachment of the chorion villi, produced by the ovum growing out o\' 
proportion to the tube in which it is contained. Whether this is the 
correct explanation or not, it is a fact that irregidar luMuorrlutge very 
generally })recedes the laceration for several days or more. Associatixl 
with the hemorrhage tlu^re may occasionally be lound shnxls oi' the 
decidual lining of the uterus, the }>resenee ot' which ^^ouKl maieriallv 
aid the diagnosis. Accompanying this hemorrhage there is ahnost 



182 



PREGNANCY. 



always more or less abdominal pain, produced by the stretching of 
the tissues in which the ovum is placed, and this is sometimes de- 
scribed as being of very intense and crampy character. If, then, we 
meet with a case in which the symptoms of early pregnancy exist, in 
which there are irregular losses of blood, possibly discharge of mem- 



FiG. 84. 




Extra-uterine Pregnancy at Term of the Tubo-ovarian Variety. (After a case of Dr. A. Sibley 
Campbeirs, of Augusta, Georgia.) 

branous shreds, and abdominal pain, a careful examination should be 
insisted on, and then the true nature of the case may possibly be 
ascertained. Should extra-uterine foetation exist, we should expect 
to find the uterus somewhat enlarged and the cervix softened, as in 
early pregnancy, but both these changes are doubtless generally less 
marked than in normal pregnancy. This fact of itself, however, is 
of little diagnostic value, for slight differences of this kind must always 
be too indefinite to justify a positive opinion. 

The existence of a periuterine tumor, rounded or oval in outline, and 
producing more or less displacement of the uterus, in the direction oppo- 
site to that in which the tumor is situated, may point to the existence of 
tubular foetation. By bimanual examination, one hand depressing the 
abdominal wall, while the examining finger of the other acts in concert 
with it either through the vagina or rectum, the size and relations of 
the growth may be made out. There are various conditions which give 



ABNORMAL PREGNANCY. 183 

rise to very similar physical signs, such as small ovarian or fibroid 
growths, or the effusion of blood around the uterus ; and the differen- 
tial diagnosis must always be very difficult, and often impossible. A 
curious example of the difficulty of diagnosis is recorded by Joulin, in 
which Huguier and six or seven of the most skilled obstetricians of 
Paris agreed on the existence of extra-uterine pregnancy, and had, in 
consultation, sanctioned an operation, when the case terminated by abor- 
tion, and proved to be a natural pregnancy. The use of the uterine 
sound, which might aid in clearing up the case, is necessarily contra- 
indicated unless uterine gestation is certainly disproved. Hence it must 
be admitted that positive diagnosis must always be very difficult. 80 
that the most we can say is, that when the general signs of early preg- 
nancy are present, associated with the other symptoms and signs alluded 
to, the suspicion of tubal pregnancy may be sufficiently strong to justify 
us in taking such action as may possibly spare the patient the necessary 
fatal consequence of rupture. 

Treatment. — If the diagnosis were quite certain, the removal of the 
entire Fallopian tube and its contents by abdominal section would be 
quite justifiable, and probably would neither be more difficult nor more 
dangerous than ovariotomy ; for at this stage of extra-uterine foetation 
there are no adhesions to complicate the operation. As yet, however, 
the uncertainty of the diagnosis has prevented the adoption of the 
practice. 

Dr. T. Gaillard Thomas of New York ^ has recorded a most instruc- 
tive case in w^hich he saved the life of the patient by a bold and judici- 
ous operation. The nature of the case was rendered pretty evident by 
the signs above described, and Thomas opened the cyst from the vagina 
by a platinum knife rendered incandescent by a galvano-caustic battery, 
by which means he hoped to prevent hemorrhage. Through the open- 
ing thus made he removed the foetus. In subsequently attempting to 
remove the placenta very violent hemorrhage took place, which was only 
arrested by injecting the cyst with a solution of persulphate of iron. 
The remains of the placenta subsequently came away piecemeal after an 
attack of septicaemia, which was kept in bounds by freely washing (nit 
the cyst with antiseptic lotion, the patient eventually recovering. If I 
might venture to make a criticism on a case followed by so brilliant a 
success, it would be that in another instance of this kind it would be 
safer to follow the rule so strictly laid down with regard to gastrotomy 
in abdominal ])regnancies, and leave the placenta untouched, trusting to 
the injection of antiseptics and the thorough drainage of the cyst to 
prevent mischief. 

[In a second operation, performed by Prof. Thomas on ^lay 10, 
1876, in a case where the fotus had been some time dead, he incised the 
abdomen throngli the linea alba, and extracted a foetus weighing nearly 
seven pounds. The cord was cut olfat its origin, and the wound closed 
except at its lower angle, where a drainage-tnbe was inserted. The pla- 
centa was removed in the middle of the foiu'tli week, and the patient 
made a good recovery. X)r. Thomas has had several similar eases ami 
results. This plan of non-interference with the placenta in the same 
^ New York Med. Journ., 1875, vol. xxi. \\ oiU. 



184 PREGNANCY. 

character of cases was first tried in New York City about ninety years 
ago by Dr. McKnigbt, and the woman recovered. He bad intended 
to peel off tbe placenta, but, fortunately, the cord was broken off in the 
operation, and be could not find it ; bence tbe result. Tbus was estab- 
lisbed tbe value of tbe metbod, altbougb it was not generally known 
until quite recently. — Ed.] 

Means of Destroying- the Vitality of the Foetus. — Another mode 
of managing these cases is to destroy tlie foetus, so as to check its fur- 
ther growth, in the hope that it may remain inert and passive within its 
sac. Various operations have been suggested and practised for this pur- 
pose. Thus, needles have been introduced into tbe tumor, through 
which currents of electricity have been passed, either the continuous 
current or, as has been suggested by Ducbenne, a spark of franklinic 
electricity. Hicks, Allen, and others have endeavored to destroy the 
foetus by passing an electro-magnetic current through it by means of a 
needle. [Dr. Allen did not resort to galvano-puncture in any one of 
his three cases. — Ed.] Many successful cases have followed the use of 
the faradic current, one pole being passed through the rectum or vagina 
to the site of the ovum, the other being placed on a point in the abdom- 
inal w^all two or three inches above Poupart's ligament ; or Apostoli's 
vaginal electrode, in which both poles are combined, might be used. 
The current should be passed daily for at least ten minutes, and con- 
tinued for a week or two until the shrinking of tbe tumor gives satis- 
factory evidence of tbe death of the foetus. This practice is per- 
fectly safe, and there can be no rational objection to its being tried. 
Aveliug makes the reasonable suggestion that tbe current acts by 
producing " tetanic contractions of tbe foetal heart due to tbe repeat- 
edly broken current of an induction machine.^' ^ Simple puncture of 
tbe cyst has been successfully practised on several occasions, either 
with a small trocar and canula or with a simple needle. A very 
interesting case, in which the development of a two months' tubal 
gestation was arrested in this way, is recorded by Greenbalgb,^ and 
another by Martin of Berlin.^ Joulin suggested tliat not only should 
the cyst be punctured, but that a solution of morphia should be injected 
into it, which by its toxic influence would ensure the destruction of the 
foetus ; and this is probably one of the best means at our disposal of 
destroying tbe foetus. Other means proposed for effecting the same 
object, such as pressure or tbe administration of toxic remedies by the 
mouth, are far too uncertain to be relied on. The simplest and most 
effectual plan Avould be to introduce the needle of an aspirator, by 
which the liquor amnii would be drawn off and the further growth of 
the foetus effectually prevented. Parry ,^ indeed, is opposed to this 
practice, and has collected several cases in which the puncture of tbe 
cyst was followed by fatal results, either from hemorrhage or septicae- 
mia. In these, however, an ordinary trocar and canula were probably 
employed, which would necessarily admit air into the sac. [Toxic 

^ '* The Diagnosis and Electrical Treatment of Early Extra-uterine Gestation," 
Brit. Gyn. Journ., 1888-89, vol. iv. p. 24. 

2 Lancet, 1867. ^ Monat. f. Gehurt.,^SQ^, Bd. xxxii. S. 140. 

* Parry on Extra-uterine Pregnancy, p. 204. 



ABNORMAL PREGNANCY. 185 

injections, even with aspiration, are very dangerous as foeticidal expe- 
dients, and the resuUs of experiments reported do not recommend their 
adoption. — Ed.] It is difficult to imagine that a fine hair-like aspira- 
ting needle, rendered perfectly aseptic by carbolic acid, could have any 
injurious results ; and it could do no harm, even if an error of diagno- 
sis had been made and the suspected extra-uterine foetation turned out 
to be some other sort of growth. If the aspirator proves that an extra- 
uterine foetation exists, then, if the cyst be of any considerable size and 
the pregnancy advanced beyond the second month, we might, if deemed 
advisable, resort to a more radical operation, such as that so successfully 
practised by Thomas. 

Treatment when Rupture has Occurred. — When the chance of 
arresting the growth of a tubular foetation has never arisen, and we first 
recognize its existence after laceration has occurred and the patient is 
collapsed from hemorrhage, what course are we to pursue ? Hitherto, 
all that has generally been done is to attempt to rally the patient by 
•stimulants, and, in the unlikely event of her surviving the immediate 
effects of laceration, endeavoring to control the subsequent peritonitis, in 
the hope that the effused blood may become absorbed, as in pelvic hsem- 
atocele. This is, indeed, a frail reed to rest upon, and when laceration 
of a tubal gestation, advanced beyond a month, has occurred, death 
has been the most certain result. It is supposed by Bernutz — and his 
opinion is shared by Barnes — that rupture which does not prove fatal is 
probably not very rare in the first few days of extra-uterine gestation, 
and that it is not an uncommon cause of certain forms of pelvic hsem- 
atocele. Unquestionably, the proper course to pursue when laceration 
has occurred is to perform gastrotomy, to sponge away the effused blood, 
and to place a ligature around the lacerated tube and remove it with its 
contents. This is no doubt a bold and heroic procedure, but no one Avho 
is acquainted with the triumphs of modern abdominal surgery can say 
that it would be either impossible or hopeless. The sponging out of 
effused blood from the abdominal cavity is an e very-day procedure in 
ovariotomy, nor is there any apparent difficulty in ligaturing and 
removing the sac of tlie extra-uterine pregnancy, for, as a rule, there 
are no adhesions formed to the surrounding parts. The history of 
these cases shows that death does not generally follow ru})ture for 
some hours, so that there Avould be usually time for the operation, 
and the extreme prostration might be, i)erhaps, temporarily counter- 
acted by transfusion. Pressure on the abdominal aorta, resorted to 
when the patient is first seen, might possibly be employed Avith advan- 
tage to check further hemorrhage until the cpiestion of oporntiini is 
decided, AVe must remember that the alternative is death, and hence 
any operation which would allbrd the slightest hope oi' success would 
be perfectly justifiable. Mr. Lawson Tait and others have on nianv 
occasions successfully o})erated inuler sucii conditions, and there can 
be no question that when the diagnosis if^ sufficiently distinct siuh a 
procedure is not only justitiabl(\ but alVords the best hope tor the 
])atient. 

Abdominal Pi'eg-nancy. — In the second of the two classes luio which, 
for ]>ractical conveniiMice, we have divided extra-uterim^ gestation the 



186 PREGNANCY. 

ovum is developed in the abdominal cavity. It is as yet an open ques- 
tion Avhetlier in some cases the pregnancy is primarily abdominal or 
not. Barnes believes that it probably never is so^ on account of the 
difficulty of admitting that so minute a body as the ovum should be able 
to fix itself on the smooth peritoneal surface. He therefore thinks that 
all abdoQiinal pregnancies are primarily either tubal or ovarian, the sac 
in Avhich they were contained having given way, and the ovum having 
retained its vitality through partial attachment to the original sac. This 
theory is opposed to that of the majority of writers, and, although it may 
perhaps render the facts less difficult to understand, it is purely hypo- 
thetical. There is no evidence to show that in most cases there is an 
early laceration of a tubal or ovarian sac. That the chorion villi do 
graft themselves upon the surrounding peritoneum is certain, and is 
observed in all cases of abdominal gestation. It is not more difficult to 
imagine them doing this from their very first development than a little 
later ; for it must be allowed that if such laceration does occur, in most 
cases it can only be when pregnancy is very slightly advanced. On the 
whole, therefore, it seems not unreasonable to admit the usual explana- 
tion of these cases, that the ovule, already impregnated, escaped the 
grasp of the Fallopian tube and fell into the abdominal cavity, where 
it rooted itself and developed. Some have, indeed, supposed that 
abdominal pregnancy may occasionally arise in consequence of spermato- 
zoa finding their way into the peritoneal cavity and there meeting and 
impregnating an ovule discharged from the Graafian follicle. Such an 
event one would suppose to be almost impossible, but Koeberle's case, 
already quoted, proves that it has actually occurred. The probability 
is that it is by no means rare for impregnated ovules to drop into the 
peritoneal cavity, and that the majority of those that do so perish with- 
out doing any harm. When they do survive, however, the chorion villi 
sprout, attach themselves to the surrounding structures, and eventually 
develop into a placenta. The mode in which the chorion villi are 
attached and the arrangement of the maternal blood-vessels have never 
yet been worked out, and would form a very interesting subject for 
investigation. The precise seat of attachment varies, and the placenta 
has been found fixed to most of the abdominal viscera, either those con- 
tained in the pelvis proper, or it may be the intestines, or to the iliac 
fossa ; most frequently, apparently, the ovum finds its way into the 
retro-uterine cul-de-sac. 

Formation of a Cyst round the Ovum. — The subsequent changes 
vary much. In the large majority of cases the ovum produces consider- 
able irritation, resulting in the exudation of plastic material, wdiich is 
thrown around it so as to form a secondary cyst or capsule, in which 
maternal vessels are largely developed, and which stretches, i^ari passu , 
with the growth of the ovum (Fig. 85). The density and strength of 
this cyst are found to be very different in different cases ; sometimes it 
forms a complete and strong covering to the ovum, at others it is very 
thin and only partially developed, but it is rarely entirely absent. As 
there is ample space for the development of the ovum, and as the sec- 
ondary cyst generally stretches and grows along with it, most cases of 
abdominal pregnancy progress without any very remarkable symptoms, 



ABNORMAL PREGNANCY. 



187 



beyond occasional severe attacks of pain, nntil the full term of preg- 
nancy has been reached. Sometimes, however, the cyst lacerates, and 
there is an escape of blood into the alxlominal cavity, accompanied by 
more or less prostration and collapse, Avliich may prove fatal, but from 
which the patient more generally rallies. The " 



fcx'tus, now dead, will 



Fig. 85. 




uterus and Foetus in a case of Abdominal Pregnancy. 



remain in the abdomen, and will undergo changes and produce results 
similar to those which we shall presently describe as occurring in cases 
progressing to the full period. 

In most cases, at the natural termination of pregnancy a strange series 
of phenomena occurs : pseudo-labor comes on, there are more or less fre- 
quent and strong uterine contractions, possibly an escape of blood from 
the vagina, the discharge of the broken-down uterine decidua, and even 
the establishment of lactation. Sometimes the contractions of the 
abdominal muscles produced by this ineffective labor have been so strong 
as to cause the laceration of the adventitious cyst surrounding the foetus 
and the escape of blood and liquor amnii into the al)dominal cavity, 
with a rapidly fatal result. JNIore frequently laceration does not occur, 
and t\\Q S})urious labor-pains continue at intervals until the fa?tus dies, 
possibly from pressure, but more often from eHusion of blood into the 
tissue of the placenta, and consequent asphyxia. Occasionally the f(Vtus 
has a})parently lived a considerable time, in some cases even lor sovm-al 
months, after the natural limit of pregnancy has been reached. 

Chang-es after the Death of the Foetus. — It is after the death o( 
the feetus that the dangers of abdominal pregnancy generally commence, 
and they are numerous and various. The subseipient t'liangts that 
occur are well worthy of study. Occasionally the ftvtus has boon 
retained for a length of time, even until the end of a long life, without 
producing any serious discomfort, and in n\any cases of this kind several 
normal pregnancies and delivcM'ic^s have subse(|uently taken place. Vacu 
when the extra-uterine gestation appears to be tolerated, and has 



188 



FEEGXAyCY. 



remained for long Avithout producing any bad effects, serious symptoms 
may be suddenly developed ; so that no woman under such circum- 
stances can be considered safe. The condition of these retained foetuses 
varies much. Most commonly the liquor amnii is absorbed, the foetus 
shrinks and dies, all its soft structures are changed into adipocere, and 
the bones only remain unaltered. Sometimes this change occurs with 
great rapidity. I have elsewhere ^ recorded a case of extra-uterine foe- 
tation in which at the full term of pregnancy the foetus ^yas alive, and 
the ^yoman died in less than a year afterward. On post-mortem the 
foetus was found entirely transformed into a greasy mass of adipo- 
cere studded with foetal bones, in which not a trace of any of the 
soft parts could be detected. On the other hand, the foetus may 
remain unchanged : in the Museum of the College of Surgeons 
there is one which w^as retained in the abdomen for fifty-two years, 
and which was found to be as fresh 
and unaltered as a newborn child. In Fig. 86. 

other cases the sac and its contents atrophy 
and shrink, and calcareous matter is de- 
posited in them, so that the whole becomes 
converted into a solid mass known as 
lithopcedion (Fig. 86). The cases, how- 
ever, in which the retention of the foetus 
gives rise to no mischief are quite excep- 
tional. Generally the foetus putrefies, and 
this may either immediately cause fatal 
peritonitis or septica3mia, or, as more com- 
monly happens, secondary inflammation 
and suppuration of the sac. Under the 
influence of the latter the sac opens exter- 
nally, either directly at some point of the 
abdominal walls, or indirectly through the 
vagina, the bowels, or even the bladder. 
Through the aperture or apertures thus 
formed (for there are often several fistulous 
openings) pus and the bones and other 
parts of the broken-down foetus are discharged ; and this may go on for 
months, and even years, until at last, if the patient's strength does not 
give way, the whole contents of the cyst are expelled and recovery takes 
place. From various statistical observations it appears that the chances 
of recovery are best when the cyst opens through the abdominal walls, 
next through the vagina or bladder, and that the foetus is discharged 
Avith most difficulty and danger when the aperture is formed into the 
bowel. At the best, however, the process is long, tedious, and full of 
danger ; and the patient too often sinks during the attempt at expulsion, 
through the irritation and exhaustion produced by the abundant and 
long-continued discharge. 

Diagnosis. — The diagnosis of abdominal gestation is by no means so 
easy as might be thought, and the most experienced practitioners have 
been mistaken with regard to it. 

^ Trans. Obstet. Soc. London, 1865, vol. vii. pp. 1-6. 




Lithopsedion. 

(From a preparation in the Museum of 

the College of Sui-geons.) 



ABNORMAL PREGNANCY. 189 

The most characteristic symptom — although this is not so common as 
in tubal gestation — is metrorrhagia combined with the general signs of 
pregnancy. Very severe and frequently repeated attacks of abdominal 
pain are rarely absent, and should at once cause susj^icion, especially if 
associated with hemorrhage and the discharge of a decidual membrane 
from the uterus. They are supposed by some to depend on intercurrent 
attacks of peritonitis, by which the foetal cyst is formed. Parry doubts 
this explanation, and attributes them partly to the distension of the cyst 
by the growing foetus and partly to pressure on the surrounding struc- 
tures. On palpation the form of the abdomen will be observed to differ 
from that of normal pregnancy, being generally more developed in the 
transverse direction, and the rounded outline of the gravid uterus can- 
not be detected. AVhen development has advanced nearly to term the 
extreme distinctness with which the foetal limbs can be felt will arouse 
suspicion. Per vaginam the os and cervix will be felt softened, as in 
ordinary pregnancy, but often displaced by the pressure of the cyst, and 
sometimes fixed by perimetritic adhesions; either of these signs is of 
great diagnostic value. 

By bimanual examination it may be possible to make out that the 
uterus is not greatly enlarged, and that it is distinctly separate from 
the bulk of the tumor; these facts, if recognized, would of them- 
selves disprove the existence of uterine gestation. The diagnosis, if 
the foetal limbs or heart-sounds could be detected, would be cleared 
up in any case by the uterine sound, which would show that the 
uterus was empty and only slightly elongated. But we must be 
careful not to resort to this test unless the existence of uterine ges- 
tation is positively disproved by other means. As, however, it places 
the diagnosis beyond a doubt, it should always be employed when- 
ever operative procedure is in contemplation. Quite recently I have 
seen a remarkable case which illustrates the importance of this rule. 
The case had been diagnosed as abdominal pregnancy by no less than 
six experienced practitioners, and was actually on the operating-table 
for the performance of laparotomy. As a precaution, having some 
doubts of the diagnosis, I suggested the passage of the sound, which 
entered into a gravid uterus, the case proving to be one of small ovarian 
tumor jammed down into Douglas' space and displacing the cervix for- 
ward. Had it not been for this precaution its true nature would certainly 
not have been detected. 

Treatment. — The treatment of abdominal gestation will alwavs be a 
subject of anxious consideration, and there is nuich ditleronco of o})inion 
as to the j)roper course to })ursue. It is pretty generally admitted that 
it is not advisable to adopt any active measures until the full term ot' 
development is reached. Puncturing the cyst with the view of destroy- 
ing the foetus and arresting its further growth has been practised, but 
there are good grounds for rejecting it, for there is not the same immi- 
nent risk of death from ruptin*e of the cyst as in tubal fuMation : and, 
even if the destruction of the tortus coidd be brought about, there would 
still be formidable dangc^i's (Vom subse(]iient attempts at elimination or 
from internal hemorrhage. 

When the fidl period lias arrived, the child being still alive, as 



190 FBEGyAyCY. 

proved by auscultation, we have to consider whether it may not be 
advisable to pei'form gastrotomy before the foetus perishes, and so at 
least save the life of the child. There are few questions of greater im- 
portance and more difficult to settle. The tendency of medical opinion 
is rather in favor of immediate operation, which is recommended by 
Velpeau, Kiwisch, Koeberle, Schroeder, Tait, and many other writers, 
whose opinion necessarily carries great weight. The arguments used in 
favor of immediate operation are that, while it affords a probability of 
saving the child, the risks to the mother, great though they undoubtedly 
are, are not greater than those which may be anticipated by delay. If 
we put off interference, the cyst may rupture during the ineffectual 
efforts at labor, and death at once ensue ; or if this does not take 
place other risks, which can never be foreseen, are always in store for the 
patient. She may sink from peritonitis or from exhaustion consequent 
on the efforts at elimination Avhich in the majority of cases are sooner or 
later set up, so that, as Barnes properly says, " the patient's life may be 
said to be at the mercy of accidents of which we have no sufficient warn- 
ing.'' On the other hand, if we delay, while we sacrifice all hope of 
saving the child, we at least give the mother the chance of the foetation 
remaining quiescent for a length of time, as certainly not unfrequently 
occurs. Thus, Campbell collected 62 cases of ultimate recovery after 
abdominal gestation, in 21 of Avhich the foetus was retained without 
injury for a number of years. Then there is the question of second- 
ary gastrotomy, which consists in operating after the death of the 
foetus when urgent symptoms have arisen — a course which is advo- 
cated by Mr. Hutchinson. In favor of this procedure it is urged 
that by delay the inflammation taking place about the cyst will have 
greatly increased the chance of adhesions having formed between it 
and the abdominal parietes, so as to shut off its contents from the 
cavity of the peritoneum. The more effectually this has been accom- 
plished, the greater are the chances of recovery. When the foetus has 
been dead for some time the vascularity of the cyst will also be less- 
ened, the placental circulation will have ceased, and that viscus will 
have become solid and touo'h, so that the dangler of hemorrhas^e will 
be much diminished. 

It will be seen, therefore, that there are arguments in favor of each of 
these views. The results of the primary operation are far less favorable 
than we should have, a priori, supposed. Since the first edition of this 
work appeared the subject has been carefully studied by Dr. Parry in 
his exhaustive treatise on Extra-uterine Fcetation. He has there 
shown that when the case is left until nature has shown the 
channel through which elimination is to be effected, the mortality is 
17.35 per cent, less than in the cases in which the primary operation 
was performed. His conclusion is that " the primary operation can- 
not be too forcibly condemned. It is not too much to say that this 
operation adds only another danger to a life already trembling in 
the balance, which the delusive hope of saving the uncertain life of 
a child does not warrant us in assuming." It is only just to remember, 
as is forcibly pointed out by Keller, that in the-se days of advanced 
abdominal surgery a better result might be anticipated than when gas- 



ABNORMAL PREGNANCY. 191 

trotomy was performed in the haphazard way which was usual before 
we had gaiued experience from ovariotomy. No doubt minute care 
in the performance of the operation, a due attention to its details — 
studiously avoiding, as much as possible, the passage of blood and the 
contents of the cyst into the peritoneal cavity — and a free use of 
antiseptics would materially lessen its peril. This- conclusion is 
well illustrated in a recent interesting paper by Thomas, who ix:;lates 
three successful cases of laparotomy in abdominal pregnancy.^ 

Mode of Performing- the Operation. — The operation, then, should 
be performed with all the precautions with which we surround ovari- 
otomy. The incision, best made in the linea alba, should not be greater 
than is necessary to extract the foetus, and may be lengthened as occasion 
requires. It has been suggested that should the head be felt presenting 
above the vagina, the intervening structures should be divided and the 
foetus withdrawn by the forceps. This procedure was actually adopted 
with success in 1816 by Dr. John King of Edisto Island, South Caro- 
lina. If there are no adhesions the walls of the cyst should be stitched 
to the margin of the incision, so as to shut it off as completely as possi- 
ble from the peritoneal cavity. This has been specially insisted on by 
Braxton Hicks, and should never be omitted. The special risk is not 
so much the wounding of the peritoneum as the subsequent entrance of 
septic matter from the cyst into its cavity. Another cardinal rule, both 
in primary and secondary gastrotomy, is to make no attempt to remove 
the placenta. Its attachments are generally so deep-seated and diffused 
that any endeavor to separate it is likely to be attended with profuse 
and uncontrollable hemorrhage, or with serious injury to the structure 
to which it is attached. Many of the failures after operating can be 
traced to a neglect of this rule. The best subsequent course to pursue, 
after removing the foetus and arresting all hemorrhage, either by ligature 
or the actual cautery, is to sponge out the cyst as gently as possible, 
sprinkle the cavity with iodoform or with equal parts of tannin and 
salicylic acid, as recommended by Freund,^ and then to bring the upper 
part of the wound into apposition with sutures, leaving the lower open, 
with the cord protruding, so as to ensure an outlet for the escape of the 
placenta as it slips down. The subsequent treatment must be specially 
directed to favor the escape of the discharge and to prevent the risk of 
septicaemia. These objects may be much aided by injections of anti- 
septic fluids, such as solution of carbolic acid or diluted C'ondy's tin id ; 
and it would probably be advisable to ])lace a drainage-tube in the lower 
angle of the wound. It may be well to point out that there it? no 
operation in which a scrupulous following of the antiseptic methixl 
on Sir Joseph Lister's principles is so likely to be useful. 

As long as the placenta is retained the danger is necessarily groat, 
and it may be many days, or even weeks, before it is disehargeil. 
When once this is effected the sac may be expected to contract, and 
eventually to close entirely. 

[In cases where the ia^tus is living and viable it is essential to success 
that both cyst and placehta shall be ligated and exsectod, step by step, 

^ Am. Journ. of Mai. Set., 1870, vi^l. Ixxvii. p. 17. 
* Edin. Med. Journ., vol. 1SS3-84, p. 5:21. 



192 FBEGyAXCY. 

until tlie T^•hole growth is removed after the child shall have been deliv- 
ered. To leave the placenta, as in cases where the foetus has been dead for 
some weeks, is to endanger the life of the woman in the vast majority of 
cases, not so much from septic poisoning as hemorrhage, or both in combi- 
nation. Until the exsective metliod was introduced by Dr. August Martin 
of Berlin, in July, 1881, there had only 1 woman escaped death out of 
20 operated upon, and in her case there was no cyst, and she made an 
exceedingly narrow escape. Since Dr. Martin performed his operation it 
has been repeated and perfected by Profs. Lazarewitch of Russia, Breisky 
of Vienna, Eastman of Indianapolis, and Olshausen of Berlin, all of the 
women recovering, and the child of the last case being alive and well at 
five months. Prof. Eastman believes his case to have been purely tubal at 
the time of operation, and he was able to form a pedicle by first clamp- 
ing and then ligating the vascular connections of the cyst and placenta ; 
after which he severed the stump. Prof. Breisky tied and exsected, 
little by little, the whole ectopic growth in his case, the placenta being 
located at the dome of the cyst ; and his form of operation is tlie one 
Avhich will be found most frequently practicable. No attempt must be 
made to separate the parts by tearing or peeling, but ligation alone can 
be relied upon to prevent sudden and, it may be, uncontrollable, hem- 
orrhage. This mode of operation gives a promise of double success in 
the form of cases almost universally fatal from 1813 to 1881. — Ed.] 

Treatment after Foetal Death. — When the foetus is dead, or when 
we have determined not to attempt primary gastrotomy, it is advisable 
to wait, very carefully watching the patient, until either the gravity- of 
her general symptoms or some positive indication of the channel through 
which nature is about to attempt to eliminate the foetus shows us that 
the time for action has arrived. If there be distinct bulging of the 
cyst in the vagina or in the retro-vaginal cul-de-sac, especially if an 
opening has formed there, we may properly content ourselves with aid- 
ing the passage of the foetus through the channel thus indicated, and 
removing the parts that present piecemeal as they come within reach, 
cautiously enlarging the aperture if necessary. [This will be generally 
found, on the average, at about ten weeks after foetal death, at which 
time placental changes have rendered the utero-placental vascular con- 
nections far less varicose in character, and exfoliation can take place 
with only a trifle of blood-loss. — Ed.] If the sac have opened into 
the intestines, the expulsion of the foetus through this channel is so 
tedious and difficult, the exhaustion attending it so likely to prove 
fatal, and the danger from decomposition of the foetus through passage 
of intestinal gas so great, that it would probably be best to attempt to 
remove it by gastrotomy, especially if it is only recently dead and the 
greater portion is still retained. 

If an opening forms at the abdominal parietes, or if the symptoms 
determine us to resort to secondary gastrotomy before this occin's, the 
operation must be performed in the same way and with the same pre- 
cautions as primary gastrotomy. Here, as before, the safety of the opera- 
tion must greatly depend on the amount and firmness of the adhesions ; 
for if the cyst be not completely shut ofP from the peritoneal cavity, the 
risks of the operation will be little less than those of primary gas- 



ABNORMAL PREGNANCY. 193 

trotomy. It would obviously materially influence our decision and 
prognosis if we could determine this point before operating. Unfortu- 
nately, it is impossible, as the experience of ovariotomists proves, to 
ascertain the existence of adhesions with any certainty. If, however, 
we find that the abdominal parietes do not move freely over the cyst, 
and if the umbilicus be depressed and immovable, the presumption is 
that considerable adhesions exist. If they are found not to be present, 
the cyst-walls should be stitched to the margin of the incision, in the 
manner already indicated, before the contents are removed. 

If the foetus has been long dead and its tissues greatly altered, its 
removal may be a matter of difficulty. In the case under my own care, 
already alluded to, the foetal structures formed a sticky mass of such a 
nature that I believe it would have been impossible to empty the cyst 
had an operation been attempted. This would be, to some extent, a 
further argument in favor of the primary operation. 

Opening" of Cyst by Caustics. — The importance of adhesions has 
led some practitioners to recommend the opening of the cyst by potassa 
fusa or some other caustic, in the hope that it would set up adhesive 
inflammation around the aperture thus formed. Several successful 
operations by this method are recorded, and it would be worth trying 
should the extreme mobility of the cyst lead us to suspect that no adhe- 
sions existed. If we have to deal with a case in which fistulous open- 
ings leading to the cyst have already formed, it may, perhaps, be 
advisable to dilate the apertures already existing, rather than make a 
fresh incision ; but in determining this point the surgeon will naturally 
be guided by the nature of the case and the character and direction of 
the fistulous openings. 

General Treatment. — It is almost needless to say anything of gen- 
eral treatment in these trying cases ; but the administration of opiates to 
allay the sufferings of the patient and the endeavor to support the 
severely-taxed vital energies by appropriate food and medication will 
form an important part of the management. Freund specially insists 
on the necessity of a careful regulation of the bowels, and on making 
milk the staple article of diet, as points of value in the management 
of cases prior to 0})eration. 

Gestation in a Bilobed Uterus. — A few words may be said as to 
gestation in the rudimentary horn of a bilobed uterus, to Avhich consid- 
erable attention has of late years been directed by the writings of Kuss- 
maul and others. It ajipears certain that many cases of sup})osed tubal 
gestation are really to be referred to this category. Althougii such cases 
are of interest pathologically, they scarcely require nuich discussion from 
a practical point of view, inasnuich as their history is pretty uearlv 
identical with that of tubal pregnancy. The rudimentarv horn is dis- 
tended by the enlarging ovum, and after a time, when further distensi(>n 
is im})ossible, laceration takes place. As a matter of fact, all the thir- 
teen cases collected by Kussuiaul terminated in this wav, and even t^i 
post-mortem examination it is often extremely dilficult to distinouisli 
them from tubal pregnancies. The best way oi' doino; so is probablv 
by observing the relations of the round liganieuts to the tumor, tor it" 
the o'cstation be tubal thev will be found attached to the lueriis on the 



i;$ 



194 



PREGNANCY. 



inner or nterine side of the cyst ; whereas if the pregnancy be in a 
rudimentary horn of the nterus they will be pushed outward and be 
external to the sac. In the latter case, moreover, the sac will be 
probably found to contain a true decidua, which is not the case in tubal 
pregnancy. The only point in which they differ is that in cornual preg- 
nancy rupture may be delayed to a somewhat later period than in tubal, 
on account of the greater distensibility of the supplementary horn. 

Missed Labor. — The term " missed labor/' is applied to an exceed- 
ingly rare class of cases in which, at the full period of pregnancy, labor 
has either not come on at all, or, having commenced, the pains have 
subsequently passed off, and the foetus is retained in utero for a very 
considerable length of time. Under such circumstances it has usually 
happened that the membranes have ruptured at or about the proper 
term, and the access of air to the foetus in utero has been followed by 

Fig. 87. 




Contents of the Cyst in Dr. Oldham's Case of Missed Labor. 

decomposition. A putrid and offensive discharge has then commenced, 
and eventually portions of the disintegrating foetus have been expelled 
jper vagineiin. This discharge may go on until the entire foetus is grad- 
ually thrown off, or more frequently the patient dies from septicaemia 
or other secondary result of the presence of the decomposing mass in 
utero. Thus, ]\IcClintock relates one case ^ in which symptoms of labor 
came on in a woman 45 years of age at the expected period of delivery, 
but passed off without tlie expulsion of the foetus. For a period of 
sixty-seven weeks a highly offensive discharge came away, wdth some 
few bones, and she eventually died wdth symptoms of pyaemia. He also 

1 Dublin Quart. Journ., Feb. and May, 1864. 



ABNORMAL PREGNANCY. 19o 

cites another case in which the patient died in the same way after the 
foetus had been retained for eleven years. 

Sometimes, when the foetus has been retained for a length of time, a 
further source of danger has been added by ulceration or destruction 
of the uterine walls, probably in consequence of an ineffectual attempt at 
its elimination. This occurred in Dr. Oldham's case (Fig. 87), in 
which the contained mass is said to have nearly worn through the ante- 
rior wall of the uterus ; and also in one reported by Sir James Simp- 
son,* in which a patient died three months after term, the foetus having 
undergone fatty metamorphosis, an opening the size of half a crown 
having formed between the transverse colon and the uterine cavity. It 
is also stated that "the uterine walls were as thin as parchment." 

In some few cases, however, probably when the entrance of air has 
been prevented, the foetus has been retained for a length of time with- 
out decomposing and without giving rise to any troublesome symptoms. 
Such a case is reported by Dr. Cheston,^ in which the fretus remained in 
utero for fifty-two years. 

The causes of this strange occurrence are altogether unknown. Gen- 
erally the foetus seems to have died some time before the proper term for 
labor, and this may have influenced the character of the pains. It is 
probably also most apt to occur in women of feeble and inert habit of 
body, possibly where there was some obstacle to the dilatation of the 
cervix which the pains were unable to overcome. Barnes suggests ^ that 
some presumed examples of missed labor " were really cases of intersti- 
tial gestation or gestation in one horn of a two-horned uterus ;" and 
Macdonald * recently recorded a very interesting case in which he per- 
formed laparotomy for what he believed to be a uterine fibroid, but 
which turned out to be one horn of a bifurcated uterus containing a foetus 
which had been retained for more than a year. He believes that most, 
if not all, cases of " missed labor " are of this kind, delivery at term 
proving impossible because of the narrow connection between the impreg- 
nated horn and the cervix. 

Muller of Nancy has attempted to prove, by a critical examination 
of published cases, that most examples of so-called " missed labor " 
were in reality cases of extra-uterine foetation in which an ineffectual 
attempt at parturition took place, the fcetus being subsequently 
retained. 

From what has been said, it will be seen that the dangers arising 
from this state are very considerable, and when once the full term has 
jxassed beyond doubt, especially if the presence of an t^fiensive dis- 
charge shows that decomposition of the fo?tus has commenced, it would 
be pro])er ])ractice to empty the uterus as soon as pc^ssible. The neces- 
sary precaution, however, is not to decide too quickly that the term has 
really passed; and therefore we must either allow suthcient time to 
elapse to make it quite certain that the case really falls under this cate- 
gory or have unequivocnl signs of the death of the llvtus and injury to 
the mother's health. If we had \o deal with the case before any exten- 
sive decomposition of the fa^tus had occurred, we probably should tind 

^ FaUu. Med. Joiini., 1805. '' Mtcf.-Chir. 3Va».s\, ISH. 

^ DifcascK of Women, p. 445. * Kifin. Mai Jouni., \o\. \^SA->'\ \\ S73. 



196 PREGyANCY. 

little difficulty in its management, for the proper course then would be 
to dilate the cervix with fluid dilators, and remove the foetus by turn- 
ing ; or before doing so we might endeavor to excite uterine action by 
pressure and ergot. If the case did not come under observation until 
disintegration of the foetus had begun, it would be more difficult to deal 
with. If the foetus had become so much broken up that it was being 
discharged in pieces, Dr. McClintock says that ^' in regard to treatment 
our measures should consist mainly of palliatives — viz. rest and hip- 
baths — to subdue uterine irritation ; vaginal injections, to secure clean- 
liness and prevent excoriation ; occasional digital examination, so as to 
detect any fragments of bone that might be presenting at the os, and to 
assist in removing them. These are plain rational measures, and 
beyond them we shall scarcely, perhaps, be justified in venturing. 
Nevertheless, under certain circumstances I would not hesitate to dilate 
the cervical canal so as to permit of examining the interior of the 
womb and of extracting any fragments of bone that may be easily 
accessible ; but unless they could thus be easily reached and removed, 
the safer course would be to defer, for the present, interfering with 
them.'^ ' 

It may be doubted, I think, whether, considering the serious results 
which are known to have followed so many cases, it Avould not, on the 
whole, be safer to make at least one decided effort, under chloroform, to 
remove as much as possible of the putrefying uterine contents after the 
OS has been fully dilated. Such a procedure would be less irritating 
than frequently-repeated endeavors to pick away detached portions of 
the foetus as they present at the os uteri. When once the os is dilated, 
antiseptic intra-uterine injections, as of diluted Condy's fluid, might 
safely and advantageously be used. Unquestionably, it would be better 
practice to interfere and empty the uterus as soon as we are quite satis- 
fied of the nature of the case, rather than to delay until the foetus has 
been disintegrated. Macdonald thinks that abdominal section would 
be the best course to pursue, either removing the sac entire or resorting 
to Porro's operation. This advice is based on the assumption that 
" missed labor " is essentially the retention of a foetus in one horn of a 
bilobed uterus — a theory which certainly cannot yet be taken as proved. 

[Causes of "Missed Labor." — From several cases that have been 
reported in the United States we find that the failure of the uterus to 
expel its contents may be due to a variety of causes. If we are certain 
that the foetus is actually in iitero, that there is no pelvic or vaginal 
obstruction, and that the uterus is itself of normal form, then we must 
look for the cause of difficulty in the organ itself. By an examination 
of our reports of Csesarean operations we find that there have been sev- 
eral cases in which the power of the uterine contractions was insuffi- 
cient to overcome the resistance to expansion in the cervix. This may 
be due either to a want of contractile force in the muscular coat, to 
a change in the tissues of the cervix as the result of inflammation, or 
to both conditions combined. Where the muscular power of the uterus 
is in its integrity, the resistance in the cervix may be such that the os 
may remain unchanged after it is slightly opened, and the patient con- 

^ Dublin Quart. Journ., vol. xxxvii. p. 314. 



ABNORMAL PREGNANCY. 107 

tinue in labor until the contractile power of the uterus is exhausted 
when all muscular contraction will cease. Efforts at expulsion may 
recur at intervals covering a period of many months, when they will 
cease finally. In two Csesarean cases in the United States, the subjects 
being black, there was found a calcareous incrustation over and around 
the internal os uteri. The first operation was performed in Virginia 
in 1828 upon a multipara of 25.^ She was taken in labor at term, and 
had pains for two or three days together, at intervals, for about four 
Aveeks, after which pains returned occasionally during fifteen months. 
The cervix admitted the index finger, and in time the foetus became 
putrid. When operated upon she had carried the foetus two years. 
There was very little hemorrhage in the operation, although the uterus 
failed to contract, and for this reason was sutured. The woman died 
in the second week, of peritonitis, following an attack of indigestion 
produced by a meal of animal food and cider. The second case, also a 
multipara, was operated upon in Georgia in 1877, after a labor of four 
days, by Dr. Theodore Starbuck, who describes the deposit as '^ ossific.'' 
Tlie child was dead, and the woman died of internal hemorrhage very 
suddenly on the third day.^ 

In a third case, also black, the cause of retention appears to have 
been a prevention of the descent of the foetus, from its arm and leg 
being secured within the uterus. The woman was 33 years old and the 
mother of one child, and was operated upon by Dr. J. C Egan of 
Shreveport, Louisiana, August 25, 1860.^ On May 4, 1857, while at 
work in the field, she felt a sudden and violent pain in the left side ; 
fainted, remained insensible so long as to be thought dead, but finally 
revived, and was pronounced four months pregnant. Labor began in 
November ; the os dilated, head presented, l3ut did not descend ; pains 
continued at intervals for a month. In the fall of 1858 an abscess 
opened, leaving a fistula 1\ inches below the umbilicus. When ope- 
rated upon nearly two years later, she was greatly emaciated and affected 
with hectic fever. The uterus being adherent, the peritoneal cavity was 
not opened. When the foetus was extracted, its left foot and hand were 
wanting, and, search being made, were found in a pouch on the left side 
of the uterus, enclosed by bauds which were cut for their liberation. 
The uterus was examined bimanually to make sure that the cervix was 
sufficiently open for drainage. The decomposed foetus had been carried 
thirty-three months after maturity. Dr. Egan believes that a jxirtial 
ruj)ture of the uterus took place at the time of her attack in the field, 
and that the arm and leg were caught in its partial cicatrization. The 
woman made a good recovery. 

Much light is thrown upon a possible way of accounting for some oi^ 
the mysterious cases of missed labor, which have been claimed to be 
extra-uterine in order to account for them, by a ease recently c^jieraied 
upon in Portland, Maine, by Dr. Stanley I\ M'arren, and kindly 
reported to me by letter. The woman was a native, of Scotch-Irish 

[^ Am. Journ. ]\re(L Sci., vol. xviii. p. 257.] 
[^ Oonuminii'iitod by the 6porator, ISSO.] 

[^N. 0. M(\L ami ^un/. ,/()((;•;(., J ulv, 1S77, p. oo ; al^o coniiminioatod bv operator. 
1878.] 



198 PBEGXAXCY. 

descent, aged 32, and mother of a child of 13. She last menstruated in 
January, 1884. Supposed accidental abortion in May, as there was 
hemorrhage ; the physician said he had removed the placenta, and there 
was a thick " molasses-like ^' discharge afterward. Dr. AVarren was 
called in a week later ; found metro-peritonitis and a tumor of about 
four inches in diameter in the right groin. The peritonitis became gen- 
eral, and Dr. W. was in attendance for fifteen days. On July 1st the 
tumor was in the median line, and foetal movements and heart-sounds 
distinct. Labor expected about October 28 ; subsec[uent gestation 
normal. AVas called October 26th, at 11 p. m. ; found no true pains; 
pain apparently abdominal, rather than uterine, and continuous in the 
back and over the sides of the uterus. Foetus transverse, Avith head to 
right; pulse 152. Xo change for several days. Second week in 
November found child dead. Next four weeks slight occasional chills, 
and temperature 102° for two or three nights, but usually normal. 
Absolutely no expulsive pains. Cervix reached with difficulty, and 
finger passed through a long tubular neck, but foetus not reached. Cer- 
vix absolutely closed from December 21st to 29th ; pulse 120, tempera- 
ture 100° to 102°. Attempted to dilate with sponge tent, but could 
not pass it into the uterine cavity. December 30th attempted to open 
cervix by digital dilatation, and succeeded finally in passing a cranio- 
clast, but the parts closed as soon as the dilators were removed. Patient 
in a profound shock. After stimulating for an hour, performed Csesa- 
rean section ; hemorrhage slight ; peritoneum adherent everywhere to 
uterus ; uterine wall J inch thick ; child presented by right arm and 
side ; placenta thin and far advanced in fatty degeneration ; no hem- 
orrhage on its removal; uterus did not contract; sutured by continuous 
stitch with catgut. Child 8J pounds. Woman rallied slightly, but 
died of shock in 28 hours. Drs. T. A. Foster and S. C. Gordon were 
associated with Dr. Warren in the management of the case. 

It would a])pear in this instance of missed labor that the changes 
produced by metro-peritonitis prevented the natural dilatation of the 
cervix and the contractile action of the muscular coat of the uterus. 
Possibly, fatty degeneration of the muscular fibres had taken place, but 
this could not be ascertained, as there was no autopsy. 

The Csesarean case of Dr. Brodie S. Herndon of Fredericksburg, 
Virginia, operated upon with success in 1845, bears a close resemblance 
in many of its features to that of Dr. Warren. The subject was a 
Avhite multipara of 30, whose pains of labor gave place to the contin- 
uous pain and other characteristic symptoms of peritonitis. This disease 
lasted a month, during which time the fluid contents of the uterus 
escaped and the vaginal discharge became very offensive. Five weeks 
after the peritonitis commenced the os uteri admitted two fingers, and 
attempts at dilatation were made, but failed. Under ergot an offensive 
placenta was expelled, but the foetus could not be removed. The 
woman being greatly wasted and her room filled with stench, the Csesa- 
rean operation was performed on November 16, forty-six days after the 
first signs of labor appeared. The uterus being adherent, the perito- 
neal cavity was not exposed ; the uterus was sponged out, but did not 
contract ; it was closed in the suturing of the abdomen. The patient 



DISEASES OF PREGNANCY. 199 

made a good recovery. As in the Warren case, the uterus became 
unsuited for performing the functions of laloor by reason of changes in 
its tissues effected by inflammatory action. — Ed.] 



CHAPTEK VII. 

DISEASES OF PREGNANCY. 

The diseases of pregnancy form a subject so extensive that they 
might well of themselves furnish ample material for a separate treatise. 
The pregnant woman is of course liable to the same diseases as the non- 
pregnant ; but it is only necessary to allude to those whose course and 
effects are essentially modified by the existence of pregnancy or which 
have some peculiar effect on the patient in consequence of her condi- 
tion. There are, moreover, many disorders which can be distinctly 
traced to the existence of pregnancy. Some of them are the direct 
results of the sympathetic irritations which are then so commonly 
observed, and of these several are only exaggerations of irritations 
w^liich may be said to be normal accompaniments of gestation. These 
functional derangements may be classed under the head of neuroses, 
and they are sometimes so slight as merely to cause temporary inconve- 
nience, at others so grave as seriously to imperil the life of the patient. 
Another class of disorders is to be traced to local causes in connection 
with the gravid uterus, and are either the mechanical results of pres- 
sure or of some displacement or morbid state of the uterus ; while the 
origin of others may be said to be complex, being partly due to sympa- 
thetic irritation, partly to pressure, and partly to obscure nutritive 
changes produced by the pregnant state. 

Derang-ements of the Digestive System. — Among the sympathetic 
derangements there are none which are more conunon, and none Avhich 
more frequently produce distress, and even danger, than those which 
affect the digestive system. Under the heading of " The Signs o^ 
Pregnancy " the frequent occurrence of nausea and vomiting has ahvady 
been discussed and its most probable causes considered (p. 147). A 
certain amount of nausea is indeed so common an accompaniment of' 
pregnancy that its consideration as one of the normal symptoms of that 
state is fully justified. AVe need here only discuss those cases in which 
the nausea is excessive and long contin.ued, and leads to serious results 
from inanition and from the constant distress it occasions. Fortunately, 
a pregnant woman may bear a surprising amoinit of nausea and sick- 
ness without constitutional injmy, so that apparently almost all aliments 
may be rejected without the nutrition of the botly very materially sut- 
fering. At times the vomiting is limited to the early part o{' the day, 
when all food is rejected, and when there is a tVe»|Ucni retching o( 



200 PBEGNANCY. 

glairy, transparent fluid, in several cases mixed with bile, while at the 
latter part of the da}^ the stomach may be able to retain a sufficient 
quantity of food and the nausea disappears. In other cases the nausea 
and vomiting are almost incessant. The patient feels constantly sick, 
and the mere taste or sight of food may bring on excessive and painful 
vomiting. The duration of this distressing accompaniment of preg- 
nancy is also variable. Generally it commences between the second and 
third months, and disappears after the woman has quickened. Some- 
times, however, it begins Avith conception, and continues unabated until 
the pregnancy is over. 

Symptoms of the Graver Cases. — In the ^vorst class of cases, 
when all nourishment is rejected and when the retching is continu- 
ous and painful, symptoms of very great gravity, which may even 
prove fatal, develop themselves. The countenance becomes haggard 
from suffering, the tongue dry and coated, the epigastrium tender on 
pressure, and a state of extreme nervous irritability, attended with rest- 
lessness and loss of sleep, becomes established. In a still more aggra- 
vated degree there is general feverishness, with a rapid, small, and 
thready pulse. Extreme emaciation supervenes, the result of wast- 
ing from lack of nourishment. The breath is intensely fetid and 
the tongue dry and black. The vomited matters are sometimes 
mixed with blood. The patient becomes profoundly exhausted, a 
low form of delirium ensues, and death may follow if relief is not 
obtained. 

Prognosis. — Symptoms of such gravity are fortunately of extreme 
rarity, but they do from time to time arise and cause much anxiety. 
Gueuiot collected 118 cases of this form of the disease, out of which 
46 died; and, out of the 72 that recovered, in 42 the symptoms 
only ceased when abortion, either spontaneous or artificially pro- 
duced, had occurred. When pregnancy is over the symptoms occa- 
sionally cease with marvellous rapidity. The power of retaining and 
assimilating food is rapidly regained and all the threatening symptoms 
disappear. 

Treatment. — In the milder forms of obstinate vomiting one of the 
first indications will be to remedy any morbid state of the primse vise. 
The bowels will not unfrequently be found to be obstinately consti- 
pated, the tongue loaded, and the breath offensive ; and when attention 
has been paid to the general state of the digestive organs by general 
aperient medicines and antacid remedies, such as bismuth and soda 
and liquor pepticus after meals, the tendency to vomiting may abate 
w^ithout further treatment. 

The careful regulation of the diet is very important. Great benefit 
is often derived from recommending the patient not to rise from the 
recumbent position in the morning until she has taken something. 
Half a cup of milk and lime-water, or a cup of strong coffee, or a 
little rum and milk or cocoa and milk, a glass of sparkling kou- 
miss, or even a morsel of biscuit, taken on waking, often has a 
remarkable effect in diminishing the nausea. When any attempt at 
swallowing solid food brings on vomiting, it is better to give up all 
pretence at keeping to regular meals, and to order such light and easily 



DISEASES OF PREGNANCY. 201 

assimilated food at sliort intervals as can be retained. Iced milk, with 
lime or soda-water, given frequently, and not more than a mouthful at 
a time, will frequently be retained when nothing else will. Cold beef- 
jelly, a spoonful at a time, Avill also be often kept down. Sparkling 
koumiss has been strongly recommended as very useful in such cases, 
and is worthy of trial. It is well, however, to bear in mind, in regu- 
lating the diet, that the stomach is fanciful and capricious, and that the 
patient may be able to retain strange and apparently unlikely articles of 
food, and that if she expresses a desire for such the experiment of letting 
her have them should certainly be tried. 

The medicines that have been recommended are innumerable, and the 
practitioner will often have to try one after the other unsuccessfully, or 
may find, in an individual case, that a remedy will prove valuable which 
in another may be altogether powerless. Amongst those most generally 
useful are effervescing draughts, containing from three to five minims 
of dilute hydrocyanic acid ; the creasote mixture of the Pharmacopoeia ; 
tincture of nux vomica, in doses of five or ten minims ; single minim 
doses of vinum ipecacuanhae, every hour in severe cases, three or four 
times daily in those which are less urgent ; salicine, in doses of three to 
five grains three times a day, recommended by Tyler Smith ; oxalate of 
cerium in the form of a pill, of which three to five grains may be given 
three times a day — a remedy strongly advocated by Sir James Simpson, 
and which occasionally is of undoubted service, but more often fails ; 
the compound pyroxylic spirit of the London Pharmacopoeia, in doses 
of five minims every four hours, with a little compound tincture of 
cardamoms — a drug which is comparatively little known, but which 
occasionally has a very marked and beneficial effect in checking vomit- 
ing; opiates in various forms — which sometimes prove useful, more 
often not — may be administered either by the mouth, in pills contain- 
ing from half a grain to a grain of opium, or in small doses of the 
solution of the bimeconate of morphia or of Battley's sedative solu- 
tion, or subcutaneously — a mode of administration which is much more 
often successful. The hydrochlorate of cocaine is said to be very 
efficacious : two grains are dissolved in five ounces of water by means 
of spirit, of which mixture a teaspoonful may be taken every hour. 
Antipyrine in ten-grain doses has sometimes proved useful. Jf there 
is much tenderness about the epigastrium, one or two leeches may be 
advantageously applied, or one-third of a grain of morphia may be 
sprinkled on the surfliceof asmall blister, or cloths saturated in laudanum 
may be kept over the pit of the stomach. The administration per 
rectum of twenty grains of chloral, combined with the same amount 
of bromide of potassium, in a small enema, is said to very useful. In 
many cases I have found that the application of a spinal ice-bag to the 
cervical vertebra^, in the manner recommended by Dr. Chapman, has 
checked the vomiting when all drugs have failed. The ice may be 
placed in one of Chapman's spinal ice-bags, and aj^plied tor halt' an 
hour or an hour twice or three times a day. It invariablv prcnUuvs a 
(H^mforting sensation of" warmth, which is always agreeabk^ to the 
]>atient. Ice may be given to suck iid lihiium, and is very uset'ul : 
while if there he mueh t^xhausliou small (Quantities et* ieed chain- 



202 PBEGNANCY. 

pagne may also be given from time to time. The application of 
the ether spray over the epigastrium has been highly recommended. 

Inasmuch as the vomiting unquestionably has its origin in the uterus, 
it is only natural that practitioners should endeavor to check it by reme- 
dies calculated to relieve the irritability of that organ. Thus, morphia 
in the form of pessaries per vaginam or belladonna applied to the cervix 
has been recommended, and the former especially is often of undoubted 
service. A pessary containing one-third to half a grain of morphia 
may be introduced night and morning without interfering with other 
methods of treatment. Dr. Henry Bennet directs especial attention to 
the cervix, Avhich, he says, is almost always congested and inflamed and 
covered with granular erosions. This condition he recommends to be 
treated by the application of nitrate of silver through the speculum. 
Dr. Clay of Manchester corroborates this view, and strongly advocates, 
especially when vomiting continues in the latter months, that one or two 
leeches should be applied to the cervix. Exception may fairly be taken 
to both these methods of treatment as being somewhat hazardous, unless 
other means have been tried and failed. I have little doubt, however, 
that in many cases a state of uterine congestion is an important factor 
in keeping up the unduly irritable condition of the uterine fibres, and 
an endeavor should always be made to lessen it by insisting on absolute 
rest in the recumbent posture. Of the importance of this precaution 
in obstinate cases there can be no question. Dr. Copeman of Xorwich 
strongly recommended dilatation of the cervix by the finger, and stated 
that he found it very serviceable in checking nausea. It is obvious that 
this treatment must be adopted with great caution, as, roughly performed, 
it might lead to the production of abortion. Dr. Hewitt's views as to 
the dependence of sickness on flexions of the uterus have already been 
adverted to, and reasons have been given for doubting the general cor- 
rectness of his theory. It is quite likely, however, that well-marked 
displacements of the uterus, either forward or back^vard, may serve 
to intensify the irritability of the organ. Cazeaux mentions an obsti- 
nate case immediately cured by replacing a retroverted uterus. A care- 
ful vaginal examination should therefore be instituted in all intractable 
cases, and if distinct displacement be detected an endeavor should be made 
to support the uterus in its normal axis. If retroverted, a Hodge's 
pessary may be safely employed; if anteverted, a small air-ball pessary, 
as recommended by Hewitt, should be inserted. I believe, however, 
that such displacements are the exception, rather than the rule, in cases 
of severe sickness. 

The importance of promoting nutrition by every means in our power 
should always be borne in mind. The effervescing koumiss, which can 
now be readily obtained, I have found of great value, as it can often be 
retained when all other aliment is rejected. The exhaustion produced 
by want of food soon increases the irritable state of the nervous sys- 
tem, and if the stomach will not retain anything we can only combat 
it by occasional nutrient enemata of strong beef-tea, yolk of egg, and 
the 'like. 

The Production of Artificial Abortion. — Finally, in the worst 
class of cases, when all treatment has failed, and when the patient has 



DISEASES OE PREGNANCY. 203 

fallen into tlie condition of extreme prostration already described, we 
may be driven to consider the necessity of producing abortion. For- 
tunately, cases justifying this extreme resource are of great rarity, but 
nevertheless there is abundant evidence that every now and then women 
do die from uncontrollable vomiting whose lives might have been saved 
had the pregnancy been brought to an end. The value of artificial 
abortion has been abundantly proved. Indeed, it is remarkable how 
rapidly the serious symptoms disappear when the uterus is emptied and 
the tension of the uterine fibres lessened. It has fortunately but rarely 
fallen to my lot to have to perform this operation for intractable vomit- 
ing. In one such case the patient was reduced to a state of the utmost 
prostration, having kept hardly any food on her stomach for many 
weeks, and when I first saw her she was lying in a state of low mutter- 
ing delirium. Within a few hours after abortion was induced all the 
threatening symptoms had disappeared, the vomiting had entirely ceased, 
and she was next day able to retain and absorb all that was given to her. 
The vahie of the operation, therefore, I believe to be undoubted. 
Where it has failed it seems to have been on account of undue delay. 
Owing to the natural repugnance which all must feel toward this plan, 
it has generally been postponed until the patient lias been too exhausted 
to rally. If, therefore, it is done at all, it should be before prostration 
has advanced so far as to render the operation useless. In these cases 
the obvious indication is to lessen the tension of the uterus at once, and 
therefore the membranes should be punctured by the uterine sound, so 
as to let the liquor amnii drain away ; and this may of itself be suffi- 
cient to accomplish the desired effect. It is almost needless to add that 
no one would be justified in resorting to this expedient without having 
his opinion fortified by consultation with a fellow-practitioner. 

Other disorders of the dig-estive system may give rise to con- 
siderable discomfort, but not to the serious peril attending obstinate 
vomiting. Amongst them are loss of appetite, acidity and heartburn, 
flatulent distension, and sometimes a capricious appetite, which assumes 
the form of longing for strange and even disgnsting articles of diet. 
Associated with these conditions there is generally derangement of the 
whole intestinal tract, indicated by furred tongue and sluggish l)owels, 
and they are best treated by remedies calculated to restore a healthy 
condition of the digestive organs, such as a light, easily-digested diet, 
mineral acids, vegetable bitters, occasional aperients, bisnuith and soda, 
and pcpsine. The indications for treatment are not different iVom those 
which accompany the same symj)toms in the non-pregnant state. 

Diarrh(x^a is an occasional accompaniment of pregnancy, often depend- 
ing on errors of diet. When excessive and continuous it has a decitlod 
tendency to induce uterine contractions, and I have iVei]nently observed 
premature labor to follow a shar]i attack of diarrhiea. Itshcndd, there- 
fore, not be negl(H't(Hl, and if at all excessive should be cheekecl bv the 
usual means, such as chalk mixture with aromatic eonlection and small 
doses of laudanum or chlorodyne. The possibilitv ot' apparent diar- 
rhoea being associated with actnal eonsti[>ati(Mi, the fluid matter fimling 
its way past the solid materials blocking up ihc intestine-, shouKl be 
borne in mind. 



204 PEEGXAXCY. 

Constipation is much more common, and is indeed a very general 
accompaniment of pregnancy, even in women who do not suffer from 
it at other times. It partly depends on the mechanical interference of 
the gravid uterus Avith the proper movements of the intestines, and 
partly on defective innervation of the bowels resulting from tlie altered 
state of the blood. The first indication will be to remedy this defect 
by appropriate diet, such as fresh fruits, brown bread, oatmeal porridge, 
etc. Some medicinal treatment will also be necessary, and in selecting 
the drugs to be used care should be taken to choose such as are mild 
and unirritating in their action and tend to improve the tone of the 
muscular coat of the intestine. A small quantity of aperient mineral 
water in the early morning, such as the Hunyadi, Friedrichshalle, or 
Pullna water, often answers very well ; or an occasional dose of the con- 
fection of sulphur; or a pill containing three or four grains of the 
extract of colocynth, with a quarter of a grain of the extract of nux 
vomica and a grain of extract of hyoscyamus at bedtime ; or a tea- 
spoonful of the compound liquorice powder in milk at bedtime. Con- 
stipation is also sometimes effectually combated by administering, twice 
daily, a pill containing a couple of grains of inspissated ox-gall, with 
a quarter of a grain of extract of belladonna. Enemata of soap and 
water are often very useful, and have the advantage of not disturb- 
ing the digestion. In the latter months of pregnancy, especially in the 
few weeks preceding delivery, the irritation produced by the collection 
of hardened feces in the bowel is a not infrequent cause of the annoy- 
ing false pains which then so commonly trouble the patient. In order 
to relieve them it will be necessary to empty the bowels thoroughly by 
an aperient, such as a good close of castor oil, to which fifteen or twenty 
minims of laudanum may be advantageously added. Should the rec- 
tum become loaded with scybalous masses, it may be necessary to break 
down and remove them by mechanical means, provided we are unable 
to effect this by copious enemata. 

Hemorrhoids. — The loaded state of the rectum so common in preg- 
nancy, combined with the mechanical effect of the pressure of the gravid 
uterus on the hemorrhoidal veins, often produces very troublesome 
symptoms from piles. In such cases a regular and gentle evacuation 
of the bowels should be secured daily, so as to lessen as much as pos- 
sible the congestion of the veins. Any of the aperients already men- 
tioned, especially the sulphur electuary, may be used. Dr. Fordyce 
Barker ^ insists that, contrary to the usual impression, one of the best 
remedies for this purpose is a pill containing a grain or a grain and a 
half of powdered aloes, with a quarter of a grain of extract of nux 
vomica, and that castor oil is distinctly prejudicial and apt to increase 
the symptoms. I have certainly found it answer well in several cases. 
When the piles are tender and swollen they should be freely covered with 
an ointment consisting of four grains of muriate of morphia to an 
ounce of simple ointment, or with the ung. gallse c. opio of the Phar- 
macopoeia ; and, if protruded, an attempt should be made to push them 
gently above the sphincter, by Avhich they are often unduly constricted. 
Relief may also be obtained by frequent hot fomentations, and some- 

^ The Puerperal Diseases, p. 33. 



DISEASES OF PREGNANCY. 205 

times, when the piles are much swollen, it will be found useful to 
puncture them, so as to lessen the congestion, before any attempt at 
reduction is made. 

Ptyalism. — A profuse discharge from the salivary glands is an occa- 
sional distressing accompaniment of pregnancy. It is generally con- 
fined to the early months, but it occasionally continues during the whole 
period of gestation, and resists all treatment, only ceasing when delivery 
is over. Under such circumstances the discharge of saliva is sometimes 
enormous, amounting to several quarts a day, and the distress and 
annoyance to the patient are very great. In one case under my care the 
saliva poured from the mouth all day long, and for several months the 
patient sat with a basin constantly by her side, incessantly emptying 
her mouth, until she was reduced to a condition giving rise to really 
serious anxiety. This profuse salivation is no doubt a purely nervous 
disorder, and not readily controlled by remedies. Astringent gargles 
containing tannin and chlorate of potash, frequent sucking of ice or of 
tannin lozenges, inhalation of turpentine and creasote, counter- irritation 
over the salivary glands by blisters or iodine, the continuous galvanic 
current applied over the parotids, the bromides, opium internally, small 
doses of belladonna or atropine, may all be tried in turn, but none of 
them can be depended on with any degree of confidence. 

Toothache and Caries of the Teeth. — Severe dental neuralgia is 
also a frequent accompaniment of pregnancy, especially in the early 
months. When purely neuralgic, quinine in tolerably large doses is 
the best remedy at our disposal ; but not unfrequently it depends on 
actual caries of the teeth, and attention should always be paid to the 
condition of the teeth when facial neuralgia exists. There is no 
doubt that pregnancy predisposes to caries, and the observation of this 
fact has given rise to the old proverb, " For every child a tooth." ]Mr. 
Oakley Coles, in an interesting paper ^ on the condition of the mouth 
and teeth during pregnancy, refers the prevalence of caries to the coex- 
istence of acid dyspepsia, causing acidity of the oral secretions. There 
is much unreasonable dread amongst practitioners as to interfering with 
the teeth during pregnancy, and some recommend that all operations, 
even stopping, should be postponed until after delivery. It seems to 
me certain that the sulferin<>: of severe toothache is likelv to o'ive rise to 
far more severe irritation than the operation required for its relief, and 
I have frequently seen badly-decayed teeth extracted during i)regnancy, 
and with only a beneficial result. 

Affections of the Respiratory Organs. — Amongst the derange- 
ments of the respiratory organs, one of the most connnon is spas- 
modic coug-h, which is often excessively troublesome. Like manv 
other of the sym})athetic derangements acconqxmying gestation, 
it is purely nervous in character, and is unaccompanied bv ele- 
vated temperature, quickened pulse, or any distinct auscultatory 
phenomena. In character it is not unlike whooping cough. The 
treatment nuist obviously be guided by the character of the cough. 
Expectorants are not likely to be of service, while benefit mav be 
derived I'rom some of th'e antispasmodic class of drugs, such as bol- 

' Trans, of (he Odon(oloiiu\d Suudi/. 



206 PREGNANCY. 

ladoniia, hydrocyanic acid, opiates, or bromide of potassium. Such 
remedies may be tried in succession, but will often be found to be 
of little value in arresting the cough. [Treatment of the cough of 
pregnancy is in some instances of great importance to the safety of the 
foetus. The late Dr. S. L. Hollingsworth of Philadelphia informed 
the writer that a lady came under his care Avho had given birth to two 
dead foetuses at separate periods while under that of a well-known 
female physician in large practice, who made light of her coughing 
attacks as simply the result of her pregnant condition. Dr. H. by ap- 
propriate treatment checked the violence of her attacks, and the third 
child was born alive. — Ed.] Dyspncea may also be nervous in cha- 
racter, and sometimes symptoms not unlike those of spasmodic asthma 
are produced. Like the other sympathetic disorders, it, as well as 
nervous cough, is most frequently observed during the early months. 
There is another form of dyspnoea, not uncommonly met with, which 
is the mechanical result of the interference with the action of the 
diaphragm and lungs by the pressure of the enlarged uterus. Hence 
this is most generally troublesome in the latter months, and con- 
tinues unrelieved until delivery or until the sinking of the uterine 
tumor which immediately precedes it. Beyond taking care that the 
pressure is not increased by tight lacing or injudicious arrangement 
of the clothes, there is little that can be done to relieve this form 
of breath lessness. 

[Unless the patient has some cardiac lesion she will find much 
relief from insomnia at night by sleeping on her back in a reclined 
position. An inclined plane may be improvised by using a four-foot 
board about eighteen inches wide, well packed with pillows, and ex- 
tending from above the middle of the bed to the head-board at an 
angle of forty-five degrees or less. The abdomen of the patient should 
be anointed, twice a day with warm olive oil or inodorous lanolin, and 
she should bend her knees in bed over a large pillow, to relax her 
abdomen and to prevent her slipping down in the bed : she, in fact, 
sits on the pillow. Her head should also be supported forAvard on a 
cross-pillow. — Ed.] 

Palpitation, like dyspnoea, may be due either to sympathetic dis- 
turbance or to mechanical interference Avith the i)roper action of the 
heart. When occurring in weakly Avomen it may be referred to the 
functional derangements Avhich accompany the chlorotic condition of 
the blood often associated Avith pregnancy, and is then best remedied by 
a general tonic regimen and the administration of ferruginous prepara- 
tions. At other times antispasmodic remedies may be indicated, and it 
is seldom sufficiently serious to call for much special treatment. 

Attacks of fainting" are not rare, especially in delicate Avomen of 
highly-developed nervous temperament, and are, perhaps, most common 
at or about the period of quickening. In most cases these attacks can- 
not be classed as cardiac, but are more probably nerA^ous in character, 
and they are rarely associated Avith complete abolition of consciousness. 
They rather, therefore, resemble the condition described by the older 
authors as h/pothemia. The patient lies in a semi-unconscious condition 
Avith a feeble pulse and Avidely dilated pupil, and this state lasts for 



DISEASES OF PREGNANCY. 207 

varyiug periods from a few minutes to half an liour or more. In one 
very troublesome case under my care the condition often recurred as 
frequently as three or four times a day. I have observed that it 
rarely occurs when the more common sympathetic phenomena of preg- 
nancy, especially vomiting, are presents Sometimes it terminates with 
the ordinary symptoms of hysteria, such as sobbing. The treatment 
should consist during the attack in the administration of diffusible 
stimulants, such as ether, sal-volatile, and valerian, the patient being 
placed in the recumbent position, with the head low. If frequently re- 
peated it is unadvisable to attempt to rally the patient by the too free 
administration of stimulants. In the intervals a generally tonic regi- 
men and the administration of ferruginous remedies are indicated. If 
they recur with great frequency the daily application of the spinal ice- 
bag has proved of jnuch service. 

Extreme Ansemia and Chlorosis. — In connection with disorders 
of the circulatory system may be noticed those which depend on the 
state of the blood. The altered condition of the blood, which has 
already been described as a physiological accompaniment of pregnancy 
(p. 143), is sometimes carried to an extent which may fairly be called 
morbid ; and either on account of the deficiency of blood-corpuscles or 
from the increase in its watery constituents a state of extreme anaemia 
and chlorosis may be developed. This may sometimes be carried to a 
very serious extent, the condition amounting to that known as '^ perni- 
cious anaemia.'^ Thus, Gusserow^ records five cases in which nothing 
but excessive anaemia could be detected, all of which ended fatally. 
Generally, when such symptoms have been carried to an extreme ex- 
tent, the patient has been in a state of chlorosis before pregnancy. In 
cases of this aggravated type the patient will probably miscarry, and 
the induction of premature labor or abortion may even become impera- 
tive. 

[The writer once made an interesting autopsy in a case of pernicious 
anaemia that went to full term* and was delivered by an accoucheur 
whose patients had escaped death from the effects of labor in private 
practice during the thirty years prior to this event. He had remarked 
some weeks before, when her appearance was commented upon by the 
writer, "that such women were not fit to have children." Death took 
])lace in three hours after the birth of a female child now grcnvn up, 
and was evidently due to an amoimt of blood-loss which would not bi* 
felt by a healthy woman. There was no external escape of blood 
after the uterus contracted, and the coagula? in the uterus and vagina 
only amounted to a few ounces. She was the most anaemic woman 
prior to her lying-in that the writer has ever seen in a })rognani 
state. — El).] 

Treatment. — The treatment nuist of course be calculated to improve 
the general nutrition and enrich the impoverished blood : a li^ht antl 
easily assimilated diet, milk, eggs, beef-tea, and animal focxl — it' it can 
be taken — attention to the proper action of the bowels, a due amount 
of stinutlants, and abundance of fresh air, will be the chiet' indications 
in the general managen'ient of the case. Medicinally, terruginous prep- 
Kin'h. f. a>/n, ISri. IhI. ii. S. -J IS. 



208 PREGNANCY. 

arations will be required. Some practitioners object, apparently without 
sufficient reason, to the administration of iron during pregnancy, as 
liable to promote abortion. This unfounded prejudice may probably 
be traced to the supposed emmenagogue properties of the preparations 
of iron; but if the general condition of the patient indicate such medi- 
cation they may be administered without any fear. Preparations of 
phosphorus, such as the phosphide of zinc or free phosphorus, also 
promise favorably and are well worthy of trial. 

Some of the more aggravated cases are associated with a considerable 
amount of serous effusion into the cellular tissue, generally limited to 
the lower extremities, but occasionally extending to the arms, face, and 
neck, and even producing ascites and pleuritic effusion. Under the 
latter circumstances this complication is, of course, of great gravity, 
and it is said that after delivery the disappearance of the serous effu- 
sion may be accompanied by metastasis of a fatal character to the lungs 
or the nervous centres. This form of oedema must be distinguished 
from the slight oedematous swelling of the feet and legs so commonly 
observed as a mechanical result of the pressure of the gravid uterus, 
and also from those cases of oedema associated with albuminuria. The 
treatment must be directed to the cause, while the disappearance of the 
effusion may be promoted by the administration of diuretic drinks^ the 
occasional use of saline aperients, and rest in the horizontal position. 

Albuminuria. — The existence of albumen in the urine of pregnant 
w^omen has for many years attracted the attention of obstetricians, and it 
is now well known to be associated, in ways still imperfectly understood, 
with many important puerperal diseases. Its presence in most cases of 
puerperal eclampsia was long ago pointed out by Lever in this country 
and Rayer in France, and its association with this disease gave rise to 
the theory of the dependence of the convulsion on ursemia, Avhich is 
generally still entertained. It has been shown of late years, especially 
by Braxton Hicks, that this association is by no means so universal as 
was supposed ; or, rather, that in some cases the albuminuria folloAvs 
and does not precede the convulsions, of which it might therefore be 
supposed to be the consequence rather than the cause; so that further 
investigations as to these particular points are still required. Modern 
researches have shown that there is an intimate connection between 
many other affections and albuminuria ; as, for example, certain forms 
of paralysis, either of special nerves, as puerperal amaurosis, or of the 
spinal system ; cephalalgia and dizziness ; puerperal mania ; and pos- 
sibly hemorrhage. It cannot, therefore, be doubted that albuminuria 
in the pregnant Avoman is liable, at any rate, to be associated Avith grave 
disease, although the present state of our knoAvledge does not enable us 
to define very distinctly its precise mode of action. 

The presence of albumen in the urine of pregnant AA^omen is far from 
a rare phenomenon. Blot and Litzman met Avith albuminuria in 20 
per cent, of pregnant Avomen ; Avhich is, how^CA^er, far above the esti- 
mate of other authors; Fordyce Barker^ thinks it occurs in about 1 
out of 25 cases, or 4 per cent.; Avhile Hofmeier^ found it in 137 out of 

^ American Jounud of Obstetrics, 1878, vol. xi. p. 449. 
2 Berlin, klin. Woch, Sept., 1878. 



DISEASES OF PREGNANCY. 209 

5000 deliveries in the Berlin Gynaecological Institution, or 2.74 ])er 
cent. As in the large majority of these cases it rapidly disappears after 
delivery, it is obvious that its presence must, in a large proportion of 
cases, depend on temporary causes, and has not always the same serious 
importance as in the non-pregnant state. This is further proved by the 
undoubted fact that albumen, ra})idly disa]:)])earing after delivery, is 
often found in urine of pregnant women who go to term and pass 
through labor without any unfavorable sym])toms. 

Pressure by the Gravid Uterus. — The ol)vious facts that in preg- 
nancy the vessels supplying the kidneys are subjected to mechanical 
pressure from the gravid uterus, and that congestion of the venous cir- 
culation of those viscera must necessarily exist to a greater or less degree, 
suggest that here we may find an explanation of the frequent occurrence 
of albuminuria. This view is further strengthened by the fact that the 
albumen rarely appears until after the fifth month, and therefore not 
until the uterus has attained a considerable size ; and also that it is com- 
paratively more frequently met with in primiparse, in whom the resist- 
ance of the abdominal parietes, and consequent pressure, must be greater 
than in women who have already borne children. It is indeed probable 
that pressure and consequent venous congestion of the kidneys have an 
important influence in its production ; but there must be, as a rule, some 
other factors in operation, since an equal or even greater amount of 
pressure is often exerted by ovarian and fibroid tumors without any 
such consequences. They are probably complex. One important con- 
dition is doubtless the increased amount of work the kidneys have to do 
in excreting the waste products of the foetus as w^ell as those of the 
mother. The increased arterial tension throughout the body associated 
with hypertrophy of the heart, known to exist in pregnancy, also 
operates in the same direction. But in the large majority of cases, 
although these conditions are present, no albuminuria exists, and they 
must therefore be looked upon as predisposing causes, to which some 
other is added before the albumen escapes from the vessels. AVhat this 
is generally escapes our observation, but probably any condition pro- 
ducing sudden hypera3mia of the kidneys and giving rise to a state 
analogous to the first stage of Bright's disease — such, for example, as 
sudden exposure to cold and impeded cutaneous action — may be suf- 
ficient to set a light to the match already prepared by the existence of 
pregnancy. It has more recently been pointed out that a transient albu- 
minuria, disappearing in a few days, is very common after delivery, and 
])r()bably depends on a catarrhal condition of the urinary tract. Inger- 
sten observed this in 50 out of 153 deliveries, and in 15 only had anv 
albumen existed before the confinement.^ In addition to these tem- 
porary causes it must not be forgotten that pregnancv mav supervene 
in a patient already suffering from Bright's disease, when of eoui*se 
the albumen will exist in the urine from the comineniviuoui oi" 
gestation. 

The various diseases associated with the [>rescuee t>f albunuMi in the 
urine will recpiire separate consideration. Some of tliese, especiallv 
puerperal eclam[)sia, are amongst the most dangerous complications o^ 

^ Zcitschrift f. Ccbart., lS7i>. Haml v. lloti -. 
14 



210 PBEGXAXCY. 

pregnancy. Others, such as paralysis, cephalalgia, dizziness, may also 
be of considerable gravity. The ])recise mode of their production, and 
^yhether they can be traced, as is generally believed, to the retention of 
urinary elements in the blood, either urea or free carbonate of ammonia 
produced by its decomposition, or ^Yhether the two are only common 
results of some undetermined cause, will be considered when we come 
to discuss puerperal convulsions. Whatever view may ultimately be 
taken on these points, it is sufficiently obvious that albuminuria in a 
pregnant woman must constantly be a source of much anxiety, and must 
induce us to look forward with considerable apprehension to the termi- 
nation of the case. 

Prognosis. — We are scarcely in possession of a sufficiently large 
number of observations to justify any very accurate conclusions as to the 
risk attending albuminuria during pregnancy, but it is certainly by no 
means slight. Hofmeier believes that albuminuria is a most severe 
complication both for woman and child, even when uncomplicated with 
eclampsia. The prognosis, he thinks, depends on whether it is acute in 
its onset — that is, coming on within a few days of labor — or is extended 
over several weeks. The former is more likely to pass entirely away 
after delivery, while in the latter there is more risk of the morbid state 
of the kidneys becoming permanent and leading to the establishment of 
Bright's disease after the jDregnancy is over. Goubeyre estimated that 
49 per cent, of primiparse who have albuminuria, and who escape 
eclampsia, die from morbid conditions traceable to the albuminuria. 
This conclusion is probably much exaggerated, but if it even approx- 
imate to the truth the danger must be very great. 

Besides the ultimate risk to the mother, albuminuria strongly predis- 
poses to abortion, no doubt on account of the imperfect nutrition of the 
foetus by blood impoverished by the drain of albuminous materials 
through the kidneys. This fact has been observed by many writers. 
A good illustration of it is given by Tanner,^ who states that 4 out of 7 
women he attended suffering from Bright's disease during pregnancy 
aborted, one of them three times in succession. 

Symptoms. — The symptoms accompanying albuminuria in preg- 
nancy are by no means uniform or constantly present. That which 
most frequently causes suspicion is the anasarca — not only the oedema- 
tous swelling of the lower limbs which is so common a consequence of 
the pressure of the gravid titerus, but also of the face and upper extrem- 
ities. Any puffiness or infiltration about the face or any oedema about 
the hands or arms should always give rise to suspicion and lead to a 
careful examination of the urine. Sometimes this is carried to an exag- 
gerated degree, so that there is anasarca of the whole body. 

Anomalous nervous symptoms — such as headache, transient dizziness, 
dimness of vision, spots before the eyes, inability to see objects dis- 
tinctly, sickness in women not at other times suffering from nausea, 
sleeplessness, irritability of temper — are also often met with, sometimes 
to a slight degree, at others very strongly developed, and should always 
arouse suspicion. Indeed, knowing as we do that many morbid states may 
be associated with albuminuria, we should make a point of carefully exam- 

^ Signs and Diseases of Pregnancy, p. 428. 



DISEASES OF PREGNANCY. 211 

ining the nrine of all patients in whom any unusually morVjid phenom- 
ena show themselves during pregnancy. 

The condition of the urine varies considerably, but it is generally 
scanty and highly colored, and, in addition to the albumen, especially in 
cases in which the albuminuria has existed for some time, we may find 
epithelium cells, tube-casts, and occasionally blood-corpuscles. 

Treatment. — The treatment must be based on what has been said as 
to the causes of the albuminuria. Of course it is out of our power to 
remove the pressure of the gravid uterus, except by inducing labor ; but 
its effects may at least be lessened by remedies tending to promote an 
increased secretion of urine, and thus diminishing the congestion of the 
renal vessels. The administration of saline diuretics, such as the acetate 
of potash or bitartrate of potash, the latter being given in the form of 
the well-known imperial drink, will best answer this indication. The 
action of the bowels may be solicited by purgatives producing watery 
motions, such as occasional doses of the compound jalap powder. Dry 
cupping over the loins, frequently repeated, has a beneficial effect in less- 
ening the renal hypersemia. The action of the skin should also be 
promoted by the use of the vapor-bath, and with this view the 
Turkish bath may be employed with great benefit and perfect safety. 
Jaborandi and pilocarpin have been given for this purpose, but have 
been found by Fordyce Barker to produce a dangerous degree of depres- 
sion. The next indication is to improve the condition of the blood by 
appropriate diet and medication. A very light and easily assimilated 
diet should be ordered, of which milk should form the staple. Tarnier^ 
has recorded several cases in which a purely milk diet was very success- 
ful in removing albuminuria. With the milk, which should be skim- 
med, we may allow white of egg or a little white fish. The tincture of 
the perchloride of iron is the best medicine we can give, and it may be 
advantageously combined with small doses of tincture of digitalis, which 
acts as an excellent diuretic. 

Finally, in obstinate cases we shall have to consider the advisability 
of inducing premature labor. The propriety of this procedure in the 
albuminuria of pregnancy has of late years been much discussed. 
Spiegelberg^ is opposed to it, while Barker^ thinks it should only be 
resorted to " when treatment has been thoroughly and perseveringly 
tried without success for the removal of sym])t()ms of so grave a cha- 
racter that their continuance would result in the death of the patient.'' 
Hofmeier,* on the other hand, is in favor of the operation, which lie 
does not think increases the risk of eclam])sia, and may avert it alt(v 
gether. I believe that, having in view the undoubted risks whiih 
attend this complication, the operation is unquestionably indicated and 
is perfectly justifiable in all cases attended with sym])toms of serious 
gravity. It is not easy to lay down any definite rules to guide our 
decision ; but I should not hesitate to adopt this resource in all cases in 
which the quantity of albumen is considerable and ])rogressively 
increasing, and in which treatment has failed to lesson the anu>unt ; and, 
above all, in every case attended with threatening svmptoms, such as 

^ Aiinal. de Gynec, 1876, torn, v. p. 41. ' Lt-hrhuch der Geburt. 

3 Avwr. Journ. of Obstet., 1878, vol. xi. p. 449. * Op. cit. 



212 PREGXANCY. 

severe headache, dizziness, or loss of sight. The risks of the operation 
are infinitesimal compared to those which the patient would run in the 
event of puerperal convulsions supervening or chronic Bright's disease 
becoming established. As the operation is seldom likely to be indi- 
cated until the child has reached a viable age, and as the albuminuria 
places the child's life in danger, w^e are quite justified in considering the 
mother's safety alone in determining on its performance. 

Diabetes. — The occurrence of pregnancy in a woman suffering from 
diabetes may lead to serious consequences, and has recently been spe- 
cially investigated by Dr. Matthews Duncan.^ This must be carefully 
distinguished from the physiological glycosuria commonly present at 
the end of pregnancy and during lactation. It is probable that diabetic 
patients are inapt to conceive, but when pregnancy does occur under 
such conditions the case cannot be considered devoid of anxiety. From 
the cases collected by Dr. Duncan it would appear that pregnancy is 
very liable to be interrupted in its course, generally by the death of the 
foetus, which has very often occurred. In some instances no bad results 
have been observed, while in others the patient has collapsed after 
delivery. Diabetic coma does not seem to have been observed. Out 
of 22 pregnancies in diabetic women, 4 ended fatally, so that the mor- 
tality is obviously very large. Too little is known on this subject to 
justify positive rules of treatment ; but if the symptoms are serious and 
increasing it would probably be justifiable to induce labor prematurely, 
so as to lessen the strain to which the patient's constitution is sub 
jected. 



CHAPTER YIII. 

DISEASES OF PEEGNANCY (CONTINUED). 

Disorders of the Nervous System. — There are many disorders of 
the nervous system met with during the course of pregnancy. Among 
the most common are morbid irritability of temper, or a state of men- 
tal despondency and dread of the results of the labor, sometimes almost 
amounting to insanity or even progressing to actual mania. These are 
but exaggerations of the highly susceptible state of the nervous system 
generally associated with gestation. Want of sleep is not uncommon, 
and if carried to any great extent may cause serious trouble from the 
irritability and exhaustion it produces. In such cases we should 
endeavor to lessen the excitable state of the nerves by insisting on the 
avoidance of late hours, overmuch society, exciting amusements, and the 
like ; while it may be essential to promote sleep by the administration 
of sedatives, none answering so well as the chloral hydrate, in combi- 

1 Obst. Trans., 1882, vol. xxiv. p. 256. 



DISEASES OF PREGNANCY. 213 

nation with large doses of the bromide of potassium or sodium^ which 
greatly intensify its hypnotic effects. 

Severe headaches and various intense neuralgise are common. 
Amongst the latter the most frequently met with are pain in the 
breasts, due to the intimate sympathetic connection of the mammse 
with the gravid uterus, and intense intercostal neuralgia, which a 
careless observer might mistake for pleuritic or inflammatory pain. 
The thermometer, by showing that there is no elevation of tempera- 
ture, would prevent such a mistake. Neuralgia of the uterus itself 
or severe pains in the groins or thighs — the latter being probably the 
mechanical results of dragging on the attachments of the abdominal 
muscles — are also far from uncommon. In the treatment of such neur- 
algic aflPections attention to the state of the general health and large 
doses of quinine and ferruginous preparations whenever there is much 
debility will be indicated. Locally sedative applications, such as l^ella- 
donna and chloroform liniments> friction with aconite ointment when 
the pain is limited to a small space, and in the worst cases the subcuta- 
neous injection of morphia, will be called for. Those pains which 
apparently dej^end on mechanical causes may often be best relieved by 
lessening the traction on the muscles by wearing a well-made elastic 
belt to support the uterus. 

Paralysis. — Among the most interesting of the nervous diseases are 
various paralytic affections. Almost all varieties of paralysis have been 
observed, such as paraplegia, hemiplegia (complete or incomplete), facial 
paralysis, and paralysis of the nerves of special sense, giving rise to 
amaurosis, deafness, and loss of taste. Churchill records 22 cases of 
paralysis during pregnancy, collected by him from various sources. A 
large number have also been brought together by Imbert-Goubeyre in 
an interesting memoir on the subject, and others are recorded bv For- 
dyce Barker, Jouliu, and other authors ; so that there can be no doubt 
of the fact that paralytic affections are common during gestation. In a 
large proportion of the cases recorded the paralyses have been asso- 
ciated with albuminuria, and are doubtless ur^emic in origin. Thus in 
19 cases related by Goubeyre albuminuria was present in all; Darcv/ 
however, found no albuminuria in 5 out of 14 cases. The dependency 
of the paralysis on a transient cause explains -the fact that in the large 
majority of these cases the paralysis was not permanent, but disap- 
peared shortly after labor. In every case of paralysis, whatever be its 
nature, special attention should be directed to the state of the urino, and 
should it be found to be albuminous labor should be at once induced. 
This is clearly the proper course to pin-sue, and we should certainly not 
be justified in running the risk that nuist attend the progress of a case 
in which so formidable a symptom has already develojuxl itself. \\'hon 
the cause has been removed the effect will also gonoi-ally rapidly disn]>- 
pear, and the prognosis is therefore, on the whole, favorable. Should 
the })aralysi8 contituie after delivery, the treatment must be such as we 
would adopt in the non-pregnant state, antl small doses of strychnia, 
along with fai-adization of the alfected limbs, would be the best reme- 
dies at our dis})osal. 

1 Thhcih- rari<, 1877. 



214 PBEGNANCY. 

There are, however, unquestionably some cases of puerperal paraly- 
sis which are not ur?emic in their origin, and the nature of which is 
somewhat obscure. Hemiplegia may doubtless be occasioned by cere- 
bral hemorrhage, as in the non-pregnant state. Other organic causes 
of paralysis, such as cerebral congestion or embolism, may, now and 
again, be met with during pregnancy, but cases of this kind must be of 
comparative rarity. Other cases are functional in their origin. Tarnier 
relates a case of hemiplegia which he could only refer to extreme anae- 
mia. Some, again, may be hysterical. Paraplegia is apparently more 
frequently unconnected with albuminuria than the other forms of paraly- 
sis ; and it may either depend on pressure of the gravid uterus on the 
nerves as they pass through the pelvis, or on reflex action, as is some- 
times observed in connection with uterine disease. When, in such 
cases, the absence of albuminuria is ascertained by frequent examination 
of the urine, there is obviously not the same risk to the patient as in 
cases depending on uraemia, and therefore it may be justifiable to allow 
pregnancy to go on to term, trusting to subsequent general treatment to 
remove the paralytic symptoms. As the loss of power here depends on 
a transient cause, a favorable prognosis is quite justifiable. Partial par- 
alysis of one lower extremity, generally the left, sometimes occurs from 
pressure of the foetal occiput, and may continue for days or weeks, with 
a gradual improvement after parturition. 

Chorea. — Chorea is not infrequently observed, and forms a serious 
complication. It is generally met with in young women of delicate 
health and in the first pregnancy. In a large proportion of the cases 
the patient has already suffered from the disease before marriage. On 
the occurrence of pregnancy the disposition to the disease again becomes 
evoked, and choreic movements are re-established. This fact may be 
explained partly by the susceptible state of the nervous system, partly 
by the impoverished condition of the blood. 

Prognosis. — That chorea is a dangerous complication of pregnancy 
is apparent by the fact that out of 56 cases collected by Dr. Barnes ^ no 
less than 17, or 1 in 3, proved fatal. Nor is it danger to life alone that 
is to be feared, for it appears certain that chorea is more apt to leave 
permanent mental disturbance Avhen it occurs during pregnancy than at 
other times. It has also an unquestionable tendency to bring on abor- 
tion or premature labor, and in most cases the life of the child is 
sacrificed. 

Treatment. — The treatment of chorea during pregnancy does not 
differ from that of the disease under more ordinary circumstances, and 
our chief reliance will be placed on such drugs as the liquor arsenicalis, 
bromide of potassium, and iron. In the severe form of the disease the 
incessant movements and the Aveariness and loss of sleep may very 
seriously imperil the life of the patient, and more prompt and radical 
measures will be indicated. If, in spite of our remedies, the parox- 
ysms go on increasing in severity, and the patient's strength appears to 
be exhausted, our only resource is to remove the most evident cause by 
inducing labor. Generally the symptoms lessen and disappear soon 
after this is done. There can be no question that the operation is per- 

J Obst. Trans., 1869, vol. x, p. 147. 



DISEASES OF PREGNANCY. 215 

fectly justifiable, and may even be essential under such circumstances. 
It should be borne in mind that the chorea often recurs in a subsequent 
pregnancy, and extra care should then always be taken to prevent 
its development. 

Tetanus. — Tetanus has not infrequently been observed in connection 
with pregnancy in the tropics, where the disease is common. In tem- 
perate climates it is exceedingly rare, and has been more often met with 
after abortion than after labor at term. Little is known of this com- 
plication of pregnancy, either as to its causation or of the modification 
of the symptoms which may show themselves. The risk to the patient, 
however, is very great. Out of 30 cases recorded — 28 by Simpson, 2 
by Wiltshire — only 6 recovered. 

Disorders of the Urinary Org-ans. — Retention of the Urine. — 
Disorders of the urinary organs are of frequent occurrence. Retention 
of urine may be met with, and this is often the result of a retroverted 
uterus. The treatment, therefore, must then be directed to the removal 
of the cause. This subject will be more particularly considered when 
we come to discuss that form of displacement (p. 219); but we may 
here point out that retention of urine, if long continued, may not only 
lead to much distress, but to actual disease of the coats of the bladder. 
Several cases have been recorded in which cystitis, resulting from uri- 
nary retention in pregnancy, eventually caused the exfoliation of the 
entire mucous membrane of the bladder,^ which was cast off, sometimes 
entire, sometimes in shreds, and occasionally Avith portions of the mus- 
cular coat attached to it. The possibility of this formidable accident 
should teach us to be careful not to allow any undue retention of urine, 
but by a timely use of the catheter to relieve the symptoms, while Ave, 
at the same time, endeavor to remove the cause. 

Irritability of the bladder is of frequent occurrence. In the early 
months it seems to be the consequence of sympathetic irritation of the 
neck of the bladder, combined with pressure, Avhile in the later months 
it is probably solely produced by mechanical causes. When severe it 
leads to much distress, the patient's rest being broken and disturbed by 
incessant calls to micturate, and the suffering induced may produce 
serious constitutional disturbances. I have elsewhere pointed out- that 
irritability of the bladder in the later months of pregnancy is frequentlv 
associated with an abnormal position of the fa^tus, which is placed trans- 
versely or obliquely. The result is either that undue pressure is apj)lied 
to the bladder or that it is drawn out of its proper position. The 
abnormal position of the foetus can readily be detected by pal]xition, 
and is readily altered by external manipulation. In some of the cases 
I have recorded altering the ])osition of the fivtus was immediately fol- 
lowed by relief, the sym])toms recurring after a time when the t'lvtus 
had again resumed an oblique position. Should the ftvtus frequently 
become displaced, an endeavor may be made to retain it in the longitu- 
dinal axis of the uterus by a proper ada})tation of bandages ov pads. 
In cases not referable to this cause we should attempt to relievo the 
bladder symptoms by appro[)riate medication, such as small doses ot' 
liquor potassie if the urine be very acid ; tincture oi' belladonna ; the 

^ Obtif. Ihtiis., 1S();>, vol. iv. p. 13. =* Ibid., IST'J. vol. xiii. \>. A'l. 



216 PREGXAyCY. 

decoction of triticum repens, an old but very serviceable remedy ; and 
vaginal sedative pessaries containing morphia or atropine. 

[In one case under the care of the Avriter the constant calls to 
urinate were due to the pressure produced by the defective head of 
an anencephalous foetus. Fortunately, relief came in a miscarriage 
at seven months. — Ed.] 

Women who have borne many children are often troubled with 
incontinence of urine during pregnancy, the water dribbling away 
on the slightest movement. Through this much irritation of the skin 
surrounding the genitals is produced, attended with troublesome excor- 
iations and eruptions. Relief may be partially obtained by lessening 
the pressure on the bladder by an abdominal belt, while the skin is 
protected by applications of simple ointment or glycerin. 

Dr. Tyler Smith has directed attention -to a phosphatic condition 
of the urine occurring in delicate women, whose constitutions are 
severely tried by gestation. This condition can easily be altered by 
rest, nutritious diet, and a course of restorative medicines, such as 
steel, mineral acids, and the like. 

Leucorrhoea. — A profuse whitish leucorrhoeal discharge is very 
common during pregnancy, especially in its latter half. The discharge 
frequently alarms the patient, but unless it is attended with disagreeable 
symptoms it does not call for special treatment. When at all excessive 
it may lead to much irritation of the vagina and external generative 
organs. The labia may become excoriated and covered with small aph- 
thous patches, and the whole vulva may be hot, swollen, and tender. 
Warty growths, similar in appearance to syphilitic condylomata, are 
occasionally developed in pregnant women, imconnected with any spe- 
cific taint and associated with the presence of an irritating leucorrhoeal 
discharge. According to Thibierge,^ these resist local applications, such 
as sulphate of copper or nitrate of silver, but spontaneously disappear 
after delivery. Inasmuch as the leucorrhoeal discharge is dependent on 
the congested condition of the generative organs accompanying preg- 
nancy, we can hope to do little more than alleviate it. In the severer 
forms, as has been pointed out by Henry Bennet, the cervix will be 
found to be abraded or covered with granular erosion, and it may be 
from time to time cautiously touched with the nitrate of silver or a 
solution of carbolic acid. Generally speaking, we must content our- 
selves with recommending the patient to wash the vagina out gently 
with diluted Condy's fluid, or with a solution of the sulpho-carbolate 
of zinc of the strength of four grains to the oimce of water, or with 
plain tepid w^ater. For obvious reasons, frequent and strong vaginal 
douches are to be avoided, but a daily gentle injection for the pur- 
pose of ablution can do no harm. 

Pruritus. — A very distressing pruritus of the vulva is frequently 
met with along with leucorrhoea, especially when the discharge is of an 
acrid character, which in some cases leads to intense and protracted suf- 
fering, forcing the patient to resort to incessant friction of the parts. 
Pruritus, however, may exist without leucorrhoea, being apparently 
sometimes of a neuralgic character, at others associated with aphthous 

^ Ai'ch. gen. de Med., 1856. 



DISEASES OF PREGNANCY. 217 

patches on tlie mucous membrane, ascarides in the rectum, or pediculi 
in the hairs of tlie mons Veneris and labia. Cases are even recorded 
in which the pruritic irritation extended over the whole body. The 
treatment is difficult and unsatisfactory. Various sedative applications 
may be tried, such as weak solutions of Goulard's lotion, or a lotion 
composed of an ounce of the solution of the muriate of morphia, 
with a drachm and a half of hydrocyanic acid, in six ounces of 
water, or one formed by mixing one part of chloroform with six of 
almond oil. A very useful form of medication consists in the insertion 
into the vagina of a pledget of cotton-wool soaked in equal parts of the 
glycerin of borax and sulphurous acid; this may be inserted at bedtime, 
and withdrawn in the morning by means of a string attached to it. 
Smearing the parts with an ointment consisting of boracic acid and 
vaseline often answers admirably. In the more obstinate cases the 
solid nitrate of silver may be lightly brushed over the vulva, or, as 
recommended by Tarnier, a solution of bichloride of mercury, of about 
the strength of two grains to the ounce, may be applied night and 
morning. The state of the digestive organs should always be attended 
to, and aperient mineral water may be usefully administered. AMien 
the pruritus extends beyond the vulva, or even in severe local cases, 
large doses of bromide of potassium may perhaps be useful in lessening 
the general hypersesthetic state of the nerves. 

CEdema of the Lower Limbs. — Some of the disorders of pregnancy 
are the direct results of the mechanical pressure of the gravid uterus. 
The most common of these are oedema and a varicose state of the 
veins of the lower extremities, or even of the vulva. The former 
is of little consequence, provided we have assured ourselves that it is 
really the result of pressure, and not of albuminuria, and it can gener- 
ally be relieved by rest in the horizontal position. A varicose state of 
the veins of the lower limbs is very common, especially in multiparse, 
in whom it is apt to continue after delivery. The varicosity is gener- 
ally limited to the superficial veins, chiefly the saphena, and the veins 
on the inner surface of the leg and thigh ; sometimes the deeper veins 
are also affected, and this is said to be accompanied by severe pain in 
the sole of the foot when the patient is standing or walking. Occasion- 
ally the veins of the vulva, and even of the vagina, are also enlarged 
and varicose, producing considerable swelling of the external genitals. 
Rest in the recumbent position and the use of an abdominal belt, so as 
to take the pressure off the veins as much as possible, are all that can 
be done to relieve this troublesome complication. If the veins of 
the legs are much swollen some benefit may be derived from an elas- 
tic stocking or a carefully applied bandage. 

Laceration of the Veins. — Serious and even fatal consoquoiuvs have 
followed the accidental laceration of the swollen veins. NVhen lacera- 
tion occnu's during or immediately after delivery — a not uncommon 
result of the pressure of the head — it gives rise to the format ion o( a 
vagiujvl thrombus. It has occasionally haj^pened from an accidental 
injury during pregnancy, j)s in the cases recorded by Simpson, in which 
death followed a kick on the pudenda, producing laceration ot' a vari- 
cose vein, or in one mentioned by Tarnier, where the patient tell on the 



218 PBEGNAXCY. 

edge of a chair. Severe hemorrhage has followed the accidental rupture 
of a vein in the leg. The only satisfactory treatment is pressure, ap- 
plied directly to the bleeding parts by means of the finger or by 
compresses saturated in a solution of the perchloride of iron. The 
treatment of vaginal thrombus following labor must be considered 
elsewhere. Occasionally the varicose veins inflame, become very tender 
and painful, and coagula form in their canals. In such cases absolute 
rest should be insisted on, while sedative lotions, such as the chloro- 
form and belladonna liniments, should be applied to relieve the pain. 

Displacements of the Gravid Uterus. — Certain displacements of 
the gravid uterus are met with which may give rise to symptoms of 
great gravity. 

Prolapse, which is rare, is almost always the result of pregnancy 
occurring in a uterus which had been previously more or less pro- 
cident. Under such circumstances the increasing weight of the uterus 
will at first necessarily augment the previously existing tendency to pro- 
lapse of the womb, which may come to protrude partially and entirely 
beyoud the vulva. In the great majority of cases, as pregnancy 
advances, the prolapse cures itself, for at about the fourth or fifth month 
the uterus will rise above the pelvic brim. It has been said that in 
some cases of complete procidentia pregnancy has gone even to term, 
with the uterus lying entirely outside the vulva. Most probably these 
cases were imperfectly observed, the greater part of the uterus being in 
reality above the pelvic brim, a portion only of its lower segment pro- 
truding externally ; or, as has sometimes been the case, the protruding 
portion has been an old-standing hypertrophic elongation of the cervix, 
the internal os uteri and fundus being normally situated. Should a pro- 
lapsed uterus not rise into the abdominal cavity as pregnancy advances, 
serious symptoms will be apt to develop themselves; for unless the pel- 
vis be unusually capacious the enlarging uterus will get jammed within 
its bony walls, the rectum and urethra will be pressed upon, defecation 
and micturition will be consequently impeded, and severe pain and 
much irritation will result. In all probability such a state of things 
would lead to abortion. The possibility of these consequences should 
therefore teach us to be careful in the management of every case of pro- 
lapse, however slight, in which pregnancy occurs. Absolute rest in the 
horizontal position should be insisted on, while the uterus should be sup- 
ported in the pelvis by a full-sized Hodge's pessary, which should be 
worn until at least the sixth month, when the uterus would be fully 
within the abdominal cavity. After delivery prolonged rest should be 
recommended, in the hope that the process of involution may be accom- 
panied by a cure of the prolapse. There can be no doubt that preg- 
nancy carried to term affords an opportunity of curing even old-stand- 
ing displacements which should not be neglected. 

Anteversion of the gravid uterus seldom produces symptoms of 
consequence. In all probability it is common enough when pregnancy 
occurs in a uterus which is more than usually anteverted or is anteflexed. 
Under such circumstances there is not the same risk of incarceration in 
the pelvic cavity as in cases in which pregnancy exists in a retroflexed 
uterus, for as the uterus increases in size it rises without difficulty 



DISEASES OF PREGNANCY. 219 

into the abdominal cavity. In the early months the pressure of the 
fundus on the bladder may account for the irritability of that viscus 
then so commonly observed. It will be remembered that Graily Hewitt 
attributes great importance to this condition as explaining the sickness 
of pregnancy — a theory^ however, which has not met with general 
acceptation. 

Extreme anteversion of the uterus at an advanced period of j)reg- 
nancy is sometimes observed in multiparse with very lax abdominal 
walls, occasionally to such an extent that the uterus falls completely 
forward and downward, so that the fundus is almost on a level with 
the patient's knees. This form of pendulous belly may be associated 
with a separation of the recti muscles, between wdiich the Avomb forms 
a ventral hernia covered only by the cutaneous textures. When labor 
comes on this variety of displacement may give rise to trouble by de- 
stroying the proper relation of the uterine and pelvic axes. The treat- 
ment is purely mechanical, keeping the patient lying on her back as 
much as possible and supporting the pendulous abdomen by a properly 
adjusted bandage. A similar forward displacement is observed in cases 
of pelvic deformity, and in the worst forms in rachitic and dwarfed 
Avomen it exists to a very exaggerated degree. 

The most important of the displacements, in consequence of its 
occasional very serious results, is retroversion of the gravid uterus. 
It was formerly generally believed that this was most commonly pro- 
duced by some accident, such as a fall, which dislocated a uterus pre- 
viously in a normal position. Undue distension of the bladder was 
also considered to have an important influence in its production by 
pressing the uterus backward and downward. 

Causes. — It is now almost universally admitted that, although the 
above-named causes may possibly sometimes produce it, in the very large 
proportion of cases it depends on pregnancy having occurred in a 
uterus previously retroverted or retroflexed. The merit of pointing 
out this fact unquestionably belongs to the late Dr. Tyler Smith, 
and further observations have fully corroborated the correctness of 
his views. 

In the large majority of cases in which pregnancy occurs in a uterus 
so displaced, as the womb enlarges it straightens itself and rises into the 
abdominal cavity, without giving any particular trouble; or, as not 
unfrequently happens, the abnormal position of the organ interferes so 
much with its enlargement as to produce abortion. Sometimes, how- 
ever, the uterus increases without leaving the pelvis until the third or 
fourth month, Avhen it can no longer be retained in the pelvic cavitv 
without inconvenience. It then presses on the uretlira and rectnni, and 
eventnally becomes completely incarcerated within the rigid walls of ihc 
bony pelvis, giving rise to characteristic symptoms. 

Symptoms. — 1lie first sign which attracts attention is generally 
sonu^ trouble connected with micturition, in conscnpience c^f pressure on 
the urethra. On examination the bladder will otten be tbuiul to he 
enormously distended, 'forming a large, fluctuating abilominal tumor 
which the patient has lost all power of emptying. Frequently small 
quantiti(\s of nrine dribbU^ away, heading the woman to believe that she 



220 PREG^^ANCY. 

has passed water, and tliiis the distension is often overlooked. Some- 
times the obstruction to the discharge of urine is so great as to lead to 
dropsical effusion into the cellular tissue of the arms and legs. This 
was very well marked in one of my cases, and disappeared rapidly after 
the bladder had been emptied. Difficulty in defecation, tenesmus, 
obstinate constipation, and inability to empty the bowels become estab- 
lished about the same time. These symptoms increase, accompanied by 
some pelvic pain and a sense of weight and bearing down, until at last 
the patient applies for advice and the true nature of the case is detected. 
When the retroversion occurs suddenly all these symptoms develop with 
great rapidity, and are sometimes very serious from the first. 

Progress and Termination. — The further progress is various. 
Sometimes, after the uterus has been incarcerated in the pelvis for more 
or less time, it may spontaneously rise into the abdominal cavity, when 
all threatening symptoms will disappear. So happy a termination is 
quite exceptional, and should the practitioner not interfere and effect 
reposition of the organ, serious and even fatal consequences may ensue, 
unless abortion occurs. 

The extreme distension of the bladder, and the impossibility of 
relieving it, may lead to laceration of its coats and fatal peritonitis ; or 
the retention of urine may produce cystitis, with exfoliation of the coats 
of the bladder; or, as more commonly happens, retention of urinary 
elements may take place, and death occur with all the symptoms of 
ur^emic poisoning. At other times the impacted uterus becomes con- 
gested and inflamed, and eventually sloughs, its contents, if the patient 
survive, being discharged by fistulous communications into the rectum 
and vagina. It need hardly be said that such terminations are only 
possible in cases which have been grossly mismanaged or the nature of 
which has not been detected till a late period. 

Diagnosis. — The diagnosis is not difficult. On making a vaginal 
examination the finger impinges on a smooth, round, elastic swelling 
filling up the lower part of the pelvis, stretching and depressing the 
posterior vaginal wall, which occasionally protrudes beyond the vulva. 
On passing the finger forward and upward we shall generally be able to 
reach the cervix, high up behind the pubes and pressing on the ure- 
thral canal. In very complete retroversion it may be difficult or impos- 
sible to reach the cervix at all. On abdominal examination the fundus 
uteri cannot be felt above the pelvic brim : this, as the retroversion does 
not give rise to serious symptoms until between the third and fourth 
months, should, under natural circumstances, always be possible. By 
bimanual examination we can make out, with due care, the alternate 
relaxation and contraction of the uterine parietes characteristic of the 
gravid uterus, and so differentiate the swelling from any other in the 
same situation. The accompanying phenomena of pregnancy will also 
prevent any mistake of this kind. 

In some few cases retroversion has been supposed to go on to term. 
Strictly speaking, this is impossible; but in the supposed examples, 
such as the well-known case recorded by Oldham, part of a retroflexed 
uterus remained in the pelvic cavity, while the greater part developed 
in the abdominal cavity. The uterus is therefore divided, as it were. 



DISEASES OF PREGNANCY. 221 

into two portions — one, wliicli is the flexed fundus, remaining in the 
pelvis, the other, containing the greater part of the foetus, rising aV^ove 
it. Under these circumstances a tumor in the vagina would exist in 
combination with an abdominal tumor, and pregnancy might go on to 
term. Considerable difficulty may even arise in labor, but the malpo- 
sition generally rectifies itself before it gives rise to any serious results. 

Treatment. — The treatment of retroversion of the gravid uterus 
should be taken in hand as soon as possible, for every day^s delay 
involves an increase in the size of the uterus, and leads, therefore, to 
greater difficulty in reposition. Our object is to restore the natural 
direction of the uterus by lifting the fundus above the promontory of 
the sacrum. The first thing to be done is to relieve the patient by 
emptying the bladder, the retention of urine having probably originally 
called attention to the case. For this purpose it is essential to use a long 
elastic male catheter of small size, as the urethra is too elongated and 
compressed to admit of the passage of the ordinary silver instrument. 
Even then it may be extremely difficult to introduce the catheter, and 
sometimes it has been found to be quite impossible. Under such cir- 
cumstances, provided reposition cannot be effected without it, the bladder 
may be punctured an inch or two above the pubes by means of the fine 
needle of an aspirator, and the urine drawn off. Dieulafoy's work on 
aspiration proves conclusively that this may be done without risk, and 
the operation has been successfully performed by Schatz and others. It 
very rarely happens, however, and in long-neglected cases only, that the 
withdrawal of the urine is found to be impossible. 

The bladder being emptied, and the bowels being also opened, if pos- 
sible, by copious enemata, we proceed to attempt reduction. For this 
purpose various procedures are adoj)ted. If the case is not of very long 
standing, I am inclined to think that the gentlest and safest plan is the 
continuous pressure of a caoutchouc bag, filled with water, placed in the 
vagina. Tlie good effect of steady and long-continued pressure of this 
kind was proved by Tyler Smith, who effected in this way the I'eduction 
of an inverted uterus of long standing, and it is not difficult to under- 
stand that it may succeed when a more sudden and violent effort fiiils. 
I have tried this plan successfully in two cases, a pyriform india-rubber 
bag being inserted into the vagina and distended as far as the patient 
could bear by means of a syringe. The water must be let out occasion- 
ally to allow the patient to empty the bladder, and the bag immediately 
refilled. In both my cases reposition occurred within twentv-four 
hours. Barnes has failed with this method ; but it succeeded so well in 
my cases, and is so obviously less likely to prove lun-tful than I'orcible 
reposition with the hand, that I am inclined to consider it the prefer- 
able procedure and one that should be tried iirst. Failing with the 
ffnid pressure, we should endeavor to replace the uterus in the following 
way: The ])atient should be ])lac(Hl at the edge i^( the bed in the ordi- 
nary obstetric position, and thoroughly ana\sthetizod. This is of import- 
ance, as it relaxes all the parts and admits of nuich t'reer manipulation 
than is otherwise possible. One or more fingers of the left hand are 
then inserted into the rectum — if the patient l)e tlec^i>ly chloroformed it 
is quite possible, with due care, even to pass the whole hand — and an 



222 PBEGXANCY. 

attempt is then made to lift or push tlie fundus above the promontory 
of the sacrum. At the same time reposition is aided by drawing down 
the cervix with the fingers of the right liand j^e?' vaginam. It has been 
insisted that the pressure should be made in the direction of one or other 
sacro-iliac synchondrosis rather than directly upward, so that the uterus 
may not be jammed against the projection of the promontory of the 
sacrum. Failing reposition through the rectum, an attempt may be 
made j:>er vaginam, and for this some have advised the upward pressure of 
the closed fist passed into the canal. Others recommend the hand-and- 
knee position as facilitating reposition, but this prevents the administra- 
tion of chloroform, w^hich is of more assistance than any change of 
position can possibly be. Various complex instruments have been 
invented to facilitate the operation, but they are all more or less danger- 
ous, and are unlikely to succeed when manual pressure has failed. 

As soon as the reduction is accomplished, subsequent descent of the 
uterus should be prevented by a large-sized Hodge's pessary, and the 
patient should be kept at rest for some days, the state of the bladder 
and bowels being particularly attended to. When reposition has been 
fairly effected a relapse is unlikely to occur. 

In cases in which reduction is found to be impossible our only 
resource is the artificial induction of abortion. Under such circum- 
stances this is imperatively called for. It is best effected by punctur- 
ing the membranes, the discharge of the liquor amnii of itself lessen- 
ing the size of the uterus, and thus diminishing the pressure to which 
the neighboring parts are subjected. After this, reposition may be pos- 
sible, or we may wait until the foetus is spontaneously expelled. It is 
not always easy to reach the os uteri, although we can generally do so 
with a curved uterine sound. If we cannot puncture the membranes, 
the liquor amnii may be drawn off through the uterine walls by means 
of the aspirator inserted through either the rectum or vagina. The 
injury to the uterine walls thus inflicted is not likely to be hurtful, and 
the risk is certainly far less than leaving the case alone. Naturally, so 
extreme a measure w^ould not be adopted until all the simpler means 
•indicated have been tried and failed. 

Diseases coexisting" with Preg-nancy. — The pregnant woman is, 
of course, liable to contract the same diseases as in the non-pregnant 
state, and pregnancy may occur in women already the subject of some 
constitutional disease. There is no doubt yet much to be learned as to 
the influence of coexisting disease on pregnancy. It is certain that some 
diseases are but little modified by pregnancy, and that others are so to 
a considerable extent, and that the influence of the disease on the foetus 
varies much. The subject is too extensive to be entered into at any 
length, but a few words may be said as to some of the more important 
affections that are likely to be met with. 

The eruptive fevers have often very serious consequences, propor- 
tionate to the intensity of the attack. Of these variola has the most 
disastrous results, which are related in the writings of the older authors, 
but which are, fortunately, rarely seen in these days of vaccination. 
The severe and confluent forms of the disease are almost certainly fatal 
to both the mother and child. In the discrete form and in modified 



DISEASES OF PREGNANCY. 223 

smallpox after vaccination the patient generally has the disearse favor- 
ably, and, although abortion frequently results, it does not necessarily 
do so. 

If scarlet fever of an intense character attacl<s a pregnant woman, 
abortion is likely to occur and the risks to the motljer are very great. 
The milder cases run their course without the production of any unto- 
ward symptoms. Should abortion occur, the well-known dangerous 
effect of this zymotic disease after delivery will gravely influence the 
prognosis. Cazeaux was of opinion that pregnant women are not apt 
to contract the disease ; while Montgomery thought that the poison 
when absorbed during pregnancy might remain latent until delivery, 
when its characteristic effects were produced. 

Measles, unless very severe, often runs its course without seriously 
affecting the mother or child. I have myself seen several examples of 
this. De Tourcoing, however, states that out of 1 5 cases the mother 
aborted in 7, these being all very severe attacks. Some cases are 
recorded in which the child was born with the rubeolous eruption 
upon it. 

The pregnant woman may be attacked with any of the continued 
fevers, and if they are at all severe they are apt to produce abortion. 
Out of 22 cases of typhoid, 16 aborted, and the remaining 6, who had 
slight attacks, went on to term ; out of 63 cases of relapsing fever, 
abortion or premature labor occurred in 23. According to Schweden, 
the main cause of danger to the foetus in continued fevers is the hyper- 
pyrexia, especially when the maternal temperature reaches 104° or 
upward. The fevers do not appear to be aggravated as regards the 
mother, and the same observation has been made by Cazeaux with 
regard to this class of disease occurring after delivery. 

Pneumonia seems to be specially dangerous, for of 1 5 cases collected 
by Grisolle,' 11 died — a mortality immensely greater than that of the 
disease in general. The larger proportion also aborted, tlie children 
being generally dead, and the fatal result is probably due, as in the 
severe continued fevers, to hyperpyrexia. The cause of the maternal 
mortality does not seem quite apparent, since the same danger does not 
appear to exist in severe bronchitis or otlier inflammatory atfections. 

Contrary to the usually received opinion, it appears certain that 
pregnancy has no I'etarding influence on coexisting phthisis, nor does 
the disease necessarily advance with greater rapidity after delivery. 
Out of 27 cases of ])hthisis collected by GrisoHe, 24 showed the lii*st 
symptoms of the diseases after pregnancy had commenced. Phthisical 
women are not apt to conceive — a fact which may probably be explaineii 
by the frequent coexistence in such eases of uterine disease, especiallv 
severe leucorrhoea. The entire duration of the plithisis seems to be 
shortened, as it averaged only nine and a half nu^nilis in the 'J 7 cases 
collected — a fiict which pi-oves at least that pregnancy has no material 
influence in arresting its })rogress. If we consider the tax on the viral 
powers whi(^h pregnancy naturally involves, we must admit that this 
view is more physiologically probable than the one generally recvivcH.!. 
and apparently adopted without any duc^ groiuids. 

^ Arch. gen. de Mid., vol. xiii. ].>. 'JiU. 



224 PREGNANCY. 

The evil effects of pregnancy and parturition on chronic heart dis- 
ease have of late received much attention from Spiegelberg, Fritsch, 
Peter, and other writers. The subject has been ably discussed ^ in a 
series of elaborate papers by Dr Angus Macdonald, which are well 
worthy of study. Out of 28 cases collected by him, 17, or 60 per 
cent., proved fatal. This, no doubt, is not altogether a reliable estimate 
of the probable risk of the complication ; but, at any rate, it shows 
the serious anxiety which the occurrence of pregnancy in a patient suf- 
fering from chronic heart-disease must cause. Dr. Macdonald refers the 
evils resulting from pregnancy in connection w^ith cardiac lesions to 
two causes : first, destruction of that equilibrium of the circulation 
which has been established by compensatory arrangements ; secondly, 
the occurrence of fresh inflammatory lesions upon the valves of the 
heart already diseased. 

The dangerous symptoms do not usually appear until after the first 
half of the pregnancy has passed, and the pregnancy seldom advances 
to term. The pathological phenomena generally met with in fatal cases 
are pulmonary congestion, especially of the bronchial mucous mem- 
brane, and pulmonary oedema, with occasional pneumonia and pleurisy. 
Mitral stenosis seems to be the form of cardiac lesion most likely to 
prove serious, and next to this aortic incompetency. The obvious 
deduction from these facts is that heart disease, especially when asso- 
ciated with serious symptoms, such as dysjDnoea, ^palpitation, and the 
like, should be considered a strong contraindication of marriage. When 
pregnancy has actually occurred, all that can be done is to enjoin the 
careful regulation of the life of the patient, so as to avoid exposure to 
cold and all forms of severe exertion. 

The important influence of syphilis on the ovum is fully considered 
elsewhere. , As regards the mother, its effects are not different from 
those at other times. It need only therefore be said that whenever 
indications of syphilis in a pregnant woman exist, the appropriate 
treatment should be at once instituted and carried on during her ges- 
tation, not only with the view of checking the progress of the disease, 
but in the hope of preventing or lessening the risk of abortion or of 
the birth of an infected infant. So far from pregnancy contraindica- 
ting mercurial treatment, there rather is a reason for insisting on it more 
strongly. As to the precise medication, it is advisable to choose a form 
that can be exhibited continuously for a length of time without produ- 
cing serious constitutional results. Small doses of the bichloride of 
mercury, such as one-sixteenth of a grain thrice daily, or of the iodide 
of mercury, or of the hydrargyrum cum creta in combination with 
reduced iron, answer the purpose well ; or in the early stages of preg- 
nancy the mercurial vapor-bath or cutaneous inunction may be 
employed. 

Dr. Weber of St. Petersburg^ has made some observations showing 
the superiority of the latter methods, which he found did not interfere 
with the course of pregnancy ; the contrary was the case when the mer- 
cury was administered by the mouth, probably, as he supposes, from 
disturbance of the digestive system. It must be borne in mind that in 

\Obst. Journ., vol. v., 1877, p. 217. ^ AUyem. Med. Cent. Zeit, Feb., 1875. 



DISEASES OF PREGNANCY. 225 

married women it may sometimes be expedient to prescribe an anti- 
syphilitic course without their knowledge of its nature, so that inunc- 
tion is not always feasible. 

The influence of pregnancy on epilepsy does not appear to be as uni- 
form as miglit perhaps be expected. In some cases the number and 
intensity of the fits have been lessened, in others the disease becomes 
aggravated. Some cases are even recorded in which epilepsy appeared 
for the first time during gestation. On account of the resemblance 
between epilepsy and eclampsia there is a natural apprehension that 
a pregnant epileptic may suffer from convulsions during delivery. 
Fortunately, this is by no means necessarily the case, and labor often 
goes on satisfactorily without any attack. 

Certain diseases of the eye are observed during pregnancy. They 
have been well studied by Mr. Power.^ One of the most common 
disturbances of vision is due to temporary impairment of accommoda- 
tion, most generally in patients who are naturally hypermetropic, and 
is dependent on exhaustion of the neuro-muscular apparatus. The 
symptoms are chiefly difficulty in reading, sewing, or other work 
requiring minute vision — pain, black spots before the eyes, lachryma- 
tion, etc. Suitable convex glasses may be required, and with attention 
to the general health the symptoms may disappear. Other diseases 
more serious and lasting in their results are also met with. Mr. Power 
describes certain important changes in the eye met with in cases of albu- 
minuria. The optic disk is swollen and congested, and irregular hem- 
orrhages and white disks are seen in the retina. The hemorrhages he 
ascribes to actual rupture of the vessels ; the white patches to a lesser 
degree of distension, admitting of the escape of white corpuscles through 
the vascular walls. In many of these cases the vision was ultimately 
regained. Another form of disease he describes is '^ white atrophy of 
the optic disk," probably following neuritis, occurring in cases in which 
there had been great loss of blood. 

Jaundice, the result of acute yellow atrophy of the liver, is occa- 
sionally observed, and is said to have been sometimes epidemic. Inde- 
pendently of the grave risks to the mother, it is most likely to produce 
abortion or the death of the foetus. According to Davidson,- it origi- 
nates in catarrhal icterus, the excretion of the bile-products being 
impeded in consequence of pregnancy, and their retention giving rise to 
the fatal blood-poisoning which accompanies the severer forms of the 
disease. Slight and transient attacks of jaundice may occur without 
being accompanied by any bad consequences. Their production is 
probably favored by the mechanical pressure of the gravid uterus on 
the intestines and the bile-ducts. 

The occurrence of ])regnancy in a woman suftering from malignant 
disease of the uterus is by no means so rare as might be sup]H)sod, and 
nuist naturally give rise to much anxiety as to the result. The obstet- 
rical treatment of these cases will be dist'ussed elsewhere. Should wo 
be aware of the existence of the disease during gestation, the question 
will arise whether we should not attempt to lessen the risks of delivery 
by bringing on abortion or premature labor. The (]u<\<tion is t^ie whii'li 

^ Barnes, Ohst. Med., vol. i. \\ 390. " Monat. f. Gduirt., ISOT. 1h1. \xx. S. 4o2. 

15 



226 PREGNANCY. 

is by no means easy to settle. AVe have to deal with a disease which is 
certain to prove fatal to the mother before long, and the progress of 
which is probably accelerated after labor, while the manipulations neces- 
sary to induce delivery may very unfavorably influence the diseased 
structures. Again, by such a measure we necessarily sacrifice the child, 
Avhile we are by no means certain that we materially lessen the danger 
to the mother. The question cannot be settled except on a considera- 
tion of each particular case. If we see the patient early in pregnancy, 
by inducing abortion Ave may save her the dangers of labor at term — 
possibly of the Csesarean section — if the obstruction be great. Under 
such circumstances the operation would be justifiable. If the pregnancy 
has advanced beyond the sixth or seventh month, unless the amount of 
malignant deposit be very small indeed, it is probable that the risks of 
labor would be as great to the mother as at term, and it w^ould then be 
advisable to give her the advantage of the few months' delay. 

Cases are occasionally met with in which pregnancy occurs in women 
who are suffering from ovarian tumor, and their proper management 
has given rise to considerable discussion. There can be no doubt that 
such cases are attended with very dangerous and often fatal conse- 
quences, for the abdomen cannot well accommodate the gravid uterus and 
the ovarian tumor, both increasing simultaneously. The result is that 
the tumor is subject to much contusion and pressure, which has some- 
times led to the rupture of the cyst and the escape of its contents into 
the peritoneal cavity; at others, to a low form of inflammation attended 
with much exhaustion, the death of the patient supervening either before 
or shortly after delivery. The danger during delivery from the same 
cause in the cases which go on to term is also very great. Of 13 cases 
of delivery by the natural powers which I collected in a paper on 
^' Labor complicated with Ovarian Tumor,'' ^ far more than one-half 
proved fatal. Another source of danger is twisting of the pedicle, and 
consequent strangulation of the cyst, of which several instances are 
recorded. It is obvious, then, that the risks are so manifold that in 
every case it is advisable to consider whether they can be lessened by 
surgical treatment. 

The means at our disposal are either to induce labor prematurely, to 
treat the tumor by tapping, or to perform ovariotomy. The question 
has been particularly discussed by Spencer Wells in his works on 
Ovariotomy^ and by Barnes in his Obstetric Operations. The former 
holds that the proper course to pursue is to tap the tumor when there is 
any chance of its being materially lessened in size by that procedure, but 
that when it is multilocular or when its contents are solid ovariotomy 
should be performed at as early a period of pregnancy as possible. 
Barnes, on the other hand, maintains that the safer course is to imitate 
the means by which nature often meets this complication, and bring on 
premature labor without interfering with the tumor. He thinks ovari- 
otomy out of the question, and that tapping may be insufficient and 
leave enough of the tumor to interfere seriously with labor. So far as 
recorded cases go, they unquestionably seem to show that tapping is 
not more dangerous than at other times, and that ovariotomy may be 

1 Ohst. Trans., 1867, vol. ix. p. 69. 



DISEASES OF PREGNANCY. 227 

practised during pregnancy with a fair amount of success. AVclls 
records 10 cases whicli were surgically interfered with. In 1 tapping 
was performed, and in 9 ovariotomy ; and of these 8 recovered, the 
pregnancy going on to term in 5. On the other hand, 5 cases were left 
alone, and either went to term or spontaneous premature labor super- 
vened ; and of these, 3 died. The cases are not sufficiently numerous 
to settle the question, but they certainly favor the view taken })y AVells 
rather than that by Barnes. It is to be observed that unless we give up 
all hope of saving the child and induce abortion, the risk of induced 
premature labor when the pregnancy is sufficiently advanced to hope for 
a viable child would almost be as great as that of labor at term ; for the 
question of interference will only have to be considered with regard to 
large tumors, which would be nearly as nmch affected by the pressure 
of a gravid uterus at seven or eight months as by one at term. Small 
tumors generally escape attention, and are more apt to be impacted 
before the presenting part in delivery. The success of ovariotomy 
during pregnancy has certainly been great ; and we have to bear in 
mind that the woman must necessarily be subjected to the risk of the 
operation sooner or later, so that we cannot judge of the case as one in 
which abortion terminates the risk. Even if the operation should put 
an end to the pregnancy — and there is at least a fair chance that it will 
not do so — there is no certainty that that would increase the risk of the 
operation to the mother, while as regards the child we should only have 
the same result as if we intentionally produced abortion. On the 
whole, then, it seems that the best chance to the mother, and certainly 
the best to the child, is to resort to the apparently heroic treatment 
recommended by Wells. The determination must, however, be to some 
extent influenced by the skill and experience of the operator. If the 
medical attendant has not gained that experience which is so essential 
for a successful ovariotomist, the interests of the mother would be best 
consulted by the induction of abortion at as early a period as possible. 
One or other procedure is essential ; for, in spite of a few cases in which 
several successive pregnancies have occurred in women who have had 
ovarian tumors, the risks are such as not to justifv an ex]^ectant practice. 
Should rupture of i\\Q cyst occur, there can be no doubt that ovariotomy 
shoidd at once be resorted to, with the view of removing the lacerated cyst 
and its extravasated contents. 

Pregnancy may occur in a uterus in which there are one or more 
fibroid tumors. During pregnancy they may lead to premature labor 
or abortion, to ])eritonitis, or they may cause so much pain and discom- 
fort from their size as to render interference imperative. If thoy are 
situated low down and in a position likely to obstruct the passage of 
the foetus, they may very seriously complicate delivery. M'hen they are 
situated in the fundus or body of the uterus they mav give rise to risk 
from hemorrhage or fronx iuHammation of their own structure. Inas- 
nuich as they are structurally similar to the uterine walls, they ]>artake 
of the growth of the uterus (hn-ing pregnancy, and frtHpiently increase 
remar(vably in size. (\^zeau\ says: "1 have known them in several 
instances to accpiire a si/o in three or four nuniths which they would 
not liave done in several years in the non-pregnant condition." C\>n- 



228 PREGNANCY. 

versely, they share in the invokition of the uterus after delivery, and 
often lessen greatly in size or even entirely disappear. Of this fact I 
have elsewhere recorded several curious examples ; ^ and many other 
instances of the complete disappearance of even large tumors have been 
described by authors whose accuracy of observation cannot be ques- 
tioned. 

The treatment will vary with the size and position of the tumor, and 
every case must be treated on its own merits, since it is not possible to 
lay down rules that will apply to all cases alike. A full report of all 
recent cases will be found in Dr. John Phillips'^ recent paper, which 
shows how serious the results often are. If the position of the tumor 
be such as to render it certain to obstruct delivery, the production of 
early abortion is perhaps the best course to pursue. It is not without 
serious risks, but probably less than allowing pregnancy to proceed to 
term. In several instances either the removal of the tumor itself by 
abdominal section (myomotomy) or the removal of the tumor and the 
gravid uterus (Miiller's ablation) has been resorted to on account of the 
grave concomitant symptoms, and with a fair measure of success. If 
the tumor is well out of the way, interference is not so urgently called 
for. The principal danger then is that the tumor will impede the post- 
partum contraction of the uterus and favor hemorrhage. Even if this 
should happen, the flooding could be controlled by the usual means, 
especially by the injection of the perchloride of iron. I have seen 
several cases in which delivery has taken place under such circum- 
stances without any untoward accident. The danger from inflamma- 
tion and subsequent extrusion of the fibroid masses would probably be 
as great after abortion or premature labor as after delivery at term. It 
seems, therefore, to be the proper rule to interfere when the tumors are 
likely to impede delivery, and in other cases to allow the pregnancy to 
go on, and be prepared to cope with any complications as they arise. 
The risks of pregnancy should be avoided in every case in which uterine 
fibroids of any size exist, the patients being advised to lead a celibate 
life. 

1 Ohst. Trans., 1869, vol. x. p. 102; 1872, vol. xiii. p. 288 ; 1877, vol. xix. p. 101. 
^ " The Management of Fibro-myomata complicating Pregnancy and Labor," Brit. 
Med. Journ., 1888, vol. i. p. 1331. 



PATHOLOGY OF THE DECIHUA AND OVUM. 



229 



CHAPTER IX. 
PATHOLOGY OF THE DECIDUA AND OVUM. 

Pathology of the Decidua. — Comparatively little is, ud fortunately, 
known of the pathological changes which occur in the mucous mem- 
brane of the uterus during pregnancy. It is probable that they are 
of much more consequence than is generally believed to be the case, and 
it is certain that they are a frequent cause of abortion. 

One of the most generally observed probably depends on endome- 
tritis antecedent to conception. When the impregnated ovule reached 
the uterus it engrafted itself on the inflamed mucous membrane, which 



Fig. 88. 




Hypertrophicd Decidua laid open, with tlio muiu attached to it*; fuudal portion. 

Duncan.^ 



(After 



was in an unfit condition for its receipt i(Ui and growth. A not un^'oin- 
mon result under such circumstances is the laceration ot' simiio ot" ihe 
decidual vessels, extravasati(Hi of the blood between thi^ deciihia and the 



230 



PEEGNAyCY. 



uterine walls, and consequent abortion at an early stage of pregnancy. 
As this morbid state of the uterine mucous membrane is likely to con- 
tinue after abortion is completed, the same history repeats itself on each 
impregnation, and thus we may have constant early miscarriages pro- 
duced. It does not necessarily follow, however, that the pregnancy is 
immediately terminated when this state of things is present. Some- 
times a condition of hyperplasia of the decidua is produced, the mem- 
brane becomes much thickened and hypertrophied in consequence of 
proliferation of its interstitial connective tissue, and the decidual cells 
are greatly increased in size (Fig. 88). In other instances the internal 
surface of the decidua becomes studded with rough polypoid growths^ 
depending on proliferation of its interstitial tissue. Duncan has found 
that the hypertrophied decidua is always in a state of fatty degeneration, 
more advanced in some places than in others.^ The result of these 
alterations is frequently to produce dwindling or death of the ovum, 
which, however, retains its connection with the decidua, until, after a 
lapse of time, the decidua is expelled in the form of a thick triangular 
fleshy substance, with the atrophied ovum attached to some part of its 
inner surface. In other cases, in which the hyperplasia has advanced to 
a less extent, the nutrition of the foetus is not interfered w^ith, and 
pregnancy may continue to term, the changes in the decidua being rec- 
ognizable after delivery. Other diseases besides endometritis may give 
rise to similar alterations in the decidua, one of these being, as Yirchow 
maintains, syphilis. The converse condition, an imperfect development 
of the decidua, especially of the decidua reflexa, has also been noted as 
a cause of abortion. The ovum will then hang loosely in the uterine 

cavity, without the support which 
Fig. 89. the growth of the decidua reflexa 

around it ought to afford, and its 
premature expulsion readilv fol- 
lows (Fig. 89). 

The peculiar condition known 
as hydrorrhoea gravidarum most 
probably depends on some obscure 
morbid state of the uterine mucous 
membrane. By it is meant a dis- 
charge of clear watery fluid at in- 
tervals during pregnancy. It may 
happen at any period of gestation, 
but is most commonly met with in 
the latter months. It may com- 
mence with a mere dribbling, or 
tliere may be a sudden and copi- 
ous discharge of fluid. Afterward 
tlie watery fluid, which is generally 
of a pale-yellowish color and trans- 
parent like the liquor amnii, may 
continue to escape at intervals for many weeks, and sometimes in very 

1 Vvrchoi'j'f^ Archil', fur Path., 1861, 1st ed. 
^ Researches in Obstetrics, p. 293. 




Imperfectly developed Decidua Vera, with the 
ovum. (After Duncan.) 



PATHOLOGY OF THE DECIDUA AND OVUM. 231 

great abundance, so as to saturate the patient^s clothes. Very frequently 
it is expelled in gushes and at night, when the patient is lying quietly 
in bed; its escape is then probably due to uterine contraction. 

Many theories have been held as to its cause. By some it is attrib- 
uted to the rupture of a cyst placed between the ovum and the uterine 
walls: Baudelocque referred it to a transudation of the liquor amnii 
through the membranes, while Burgess and Dubois believed it to 
depend on a laceration of the membranes at a distance from the os 
uteri ; Mattel more recently has attributed it to the existence of a 
sac between the chorion and the amnion. It may be that in some 
instances a single discharge of fluid may come from one of the two last- 
mentioned causes. But if it be continuous or repeated, another source 
must be sought for. Heger^ maintains that it is the result of abundant 
secretion from the glands of the mucous membrane, which are in a 
state of chronic inflanmiation, the fluid accumulating between the 
decidua and chorion and escaping through the os uteri. If this 
occur, the decidua is probably in an hypertrophied and otherwise 
morbid state. Hydrorrhoea is chiefly of interest from the error of 
diagnosis it is likely to give rise to; for on being summoned to a 
case in which watery discharge has occurred for the first time, we 
are naturally apt to suppose that the membranes have ruptured and 
that labor is imminent. Nor is there any very certain means of decid- 
ing if this be so. In hydrorrhoea we find that pains are absent, the os 
uteri unopened, and ballottement may be made out. Even if the mem- 
branes be ruptured there will be no indication for interference unless 
labor has actually commenced; and the repetition of the discharge and 
the continuance of the pregnancy will soon clear up the diagnosis. 
Hydrorrhoea, although apt to alarm the ])atient, need not give rise 
to any anxiety. The pregnancy generally progresses favorably to 
the full period, although in exceptional cases premature labor may 
supervene. No treatment is necessary, nor is there any that could 
have the least effect in controllinp; the discharo^e. 

Pathology of the Chorion. — The only important disease of the 
chorion with which we are acquainted is the Avell-known condition 
which is variously described as uterine hydatids, cystic disease of the 
ovum, hydatidifonn degeneration of the chorion, or vesicular mole. The 
name of uterine hydatids was long given to it on the supposition that 
the grape-like vesicles which characterize the disease were true hydatids, 
similar to those which develop in the liver and other structures. This 
idea has long been ex})loded, and it is now known as a certainty that 
the disease originates in the villi of the chorion. The precise mode and 
the causes of its production are, however, not yet satisfactorily settled. 
The disease is characterized by the existence in the cavitv of the uterus 
of a large number of translucent vesicles, containing a clear lim]Md 
fluid which has been found on analysis to bear close resemblance to the 
liquor amnii. Tiiese small bladder-like bodies, which vary in si/.e 
from that of a millet-seed to an acorn, are often described as resembling 
a bunch of grapes or currants. On more minute examination they are 
found not to be each attached to independent pedicles, as is the ease in 

' ^fona(. f. Gdmrt., 18(k>. 1h1. xxii. S. 429. 



232 



PREGNANCY. 



Fig. 90. 




a bunch of grapes, but some of them grow from other vesicles, while 

others have distinct pedicles attached to the 
chorion, the pedicles themselves sometimes 
being distended by fluid (Fig. 90). This 
peculiar arrangement of the vesicles is ex- 
plained by their mode of growth. 

Causes. — There has been considerable 
discussion as to the etiology of this disease. 
By some it is supposed always to follow 
death of the foetus ; and, the wdiole devel- 
opmental energy being expended on the 
chorion, which retains its attachment to the 
decidua, the result is its abnormal growth 
and cystic degeneration. This is the view 
maintained by Gierse and Graily Hewitt, 
and it is favored by the undoubted fact 
that in almost all cases the foetus has en- 
tirely disappeared, and by the occasional 
occurrence of cases of twin conceptions in 
which one chorion has degenerated, the 
other remaining healthy until term. On 
the other hand, it is maintained that the 
starting-point is connected with the mater- 
nal organism. Virchow thinks it origi- 
nates in a morbid state of the decidua, 
while others have attributed it to some 
blood-dyscrasia on the part of the mother, 
such as syphilis. There are many reasons for believing that causes of 
this nature may originate the affection. Thus, it is often found to occur 
more than once in the same person, and alterations of a similar kind, 
although limited in extent, are not unfrequently found in connection 
with the placenta and membranes of living children. On this theory 
tlie death of the foetus is secondary, the consequence of impaired nutri- 
tion from the morbid state of the chorion. The probability is that both 
views may be right, the disease sometimes following the death of the 
embryo, and at others being the result of obscure maternal causes. 

Pathology. — The degeneration of the chorion villi generally com- 
mences at an early period of pregnancy, before the placenta has com- 
menced to form. In that case the entire superficies of the chorion 
becomes affected. The disease, however, may not begin until after the 
greater part of the chorion villi have atrophied, and then it is limited 
to the placenta. The epithelium of the villi appears to be the ]3art first 
affected, and the whole interior of the diseased villus becomes filled with 
cells. The connective tissue of the villus undergoes a remarkable pro- 
liferation, and collects in masses at individual spots, the remainder of 
the villus being unaffected. By the growth of these elements the villus 
becomes distended, and many of the cells liquefy, the intercellular fluid 
thus produced widely separating the connective tissue, so as to form a 
network in the interior of the villus.^ Thus are formed the peculiar 

* Braxton Hicks, Guy's Hospital Reports, vol. ii. 3d series, p. 380. 



Hydatidiform Degeneration of the 
Chorion. 



PATHOLOGY OF THE DECIDUA AND OVUM. 233 

grape-like bodies which characterize the disease. When once the degen- 
eration has commenced the diseased tissue has a remarkable power of 
increase, so that it sometimes forms a mass as large as a child's head and 
sev^eral pounds in weiglit. 

The nutrition of the altered chorion is maintained by its connection 
with the decidua, which is also generally diseased and hypertrophied. 
Sometimes the adhesion of the mass to the uterine walls is very firm, 
and may interfere with its expulsion ; while in a few rare cases it has 
been found that the villi have forced their way into the suVjstance of the 
uterus, chiefly through the uterine sinuses, and thus caused atrophy and 
thinning of its muscular structure. Cases of this kind are related by 
Yolkmann, Waldeyer,^ and Barnes, and it is obvious that the intimate 
adhesion thus affected must seriously add to the gravity of the prog- 
nosis. 

Taking this view of the etiology of this disease, it is obvious that it 
is essentially connected with pregnancy, and that there would be no 
valid ground for maintaining, as has sometimes been done, that it may 
occur independently of conception. It is just possible, however, that 
true entozoa may form in the substance of the uterus, which, being 
expelled j)er vaginam, might be taken for the results of cystic disease, 
and thus give rise to groundless suspicions as to the patient's chastity. 

Hewitt has related one case in which true hydatids, originally formed 
in the liver, had extended to the peritoneum, and were about to burst 
through the vagina at the time of death. This occurred in an unmar- 
ried woman. One or two other examples of true hydatids forming in 
the substance of the uterus are also recorded. A very interesting case 
is also related by Hewitt,^ in which undoubted acephalocysts were 
expelled from the uterus of a patient who ultimately recovered. A 
careful examination of the cyst and its contents would show their true 
nature, as the echinococci heads with their characteristic booklets would 
be discoverable by the microscope. 

It is also possible that unfounded suspicions might arise from the 
fact of a patient expelling a mass of hydatids long after impregnation. 
In the case of a widow or woman living apart from her husband serious 
mistakes might thus be made. This has been especially pointed out by 
McClintock,^ who says : ^' Hydatids may be retained in ufero for many 
months or years, or a portion only may be exj^ellcd, and the residue 
may throw out a fresh crop of vesicles, to be discharged on a future 
occasion." 

Symptoms and Progress. — The symptoms of cystic disease of the 
ovum are by no means well marked. At first there is nothing to point to the 
existence of any morbid condition, but as pregnancy advances its ordinary 
course is interfered with. There is more general disturbance of tlie 
health than there ought to be, and the reflex irritations, such as vomit- 
ing, may be unusually develo})ed. The first jihysical sign remarked is 
rapid increase of the uterine tumor, which soon does not correspond in 
size to the supposed ])eriod of pregnanty. Thus at the third month 
the uterus may be found io reach up to or Inyond the umbilicus. .Vhout 

' Virchow's Archie, vol. xliv. p. 80. '^ Obst. Tran.^., 187 1. vol. xii. p. -'S7. 

^ McClintock's Diseases of Women, p. 398. 



234 PREGNANCY. 

this time there generally are more or less profuse watery and sanguine- 
ous discharges, which have been described as resembling currant-juice. 
They no doubt depend on the breaking down and expulsion of the 
cysts, caused by painless uterine contractions. They are sometimes 
excessive in amount, recur with great frequency, and often reduce the 
patient extremely. Portions of cysts may now generally be found 
mingled with the discharge, and sometimes large masses of them are 
expelled from time to time. Indeed, the discovery of portions of cysts 
is the only certain diagnostic sign. Vaginal examination, before the os 
has dilated, will give no information except the absence of ballottement. 
An unusual hardness or density of the uterus — described by Leishman, 
who attributes much importance to it, as ^^ a peculiar doughy, boggy 
feeling ^^ — has been pointed out by several writers. The contour of the 
uterine tumor, moreover, is often irregular. In addition, we of course 
fail to discover the usual auscultatory signs of pregnancy. All this 
may aid in diagnosis, but nothing except the presence of cysts in the 
watery bloody discharge Avill enable us to pronounce with certainty as 
to the nature of the disease. 

Treatment. — As soon as the diagnosis is established the indications 
for treatment are obvious. The sooner the uterus is cleared of its con- 
tents the better. Ergot may be given with advantage to favor uterine 
contraction and the expulsion of the diseased ovum. Should this fail, 
more especially if the hemorrhage be great, the fingers or the whole 
hand must be introduced into the uterus and as much as possible of the 
mass removed. As the os is likely to be closed, its preliminary dilata- 
tion by sponge or laminaria tents, or by a Barnes' bag if it be already 
opened to some extent, will in most cases be required. If chloroform 
be then administered, the remaining steps of the operation will be easy. 
On account of the occasional firm adhesions of the cystic mass to the 
uterus, too energetic attempts at complete separation should be 
avoided. Any severe hemorrhage after the operation can be controlled 
by swabbing out the uterine cavity with the perchloride-of-iron solu- 
tion. 

Under the name of myxoma fibrosum (Fig. 91) a more rare degen- 
eration of the chorion has been described by Yirchow and Hilde- 
brandt,^ characterized not by vesicular but fibroid degeneration of 
the connective tissue of the chorion. It results in the enlargement of 
the chorionic villi by fibrous hypertrophy, forming distinct tumors in the 
placental structure, and is more frequently met with in the later than the 
earlier periods of pregnancy. It does not, therefore, necessarily lead to 
the death of the child.^ 

Pathology of the Placenta. — The pathology of the placenta has of 
late years attracted much attention, and it has an important practical 
bearing in consequence of its effect on the child. 

Placentae vary considerably in shape. They may be crescentic or 
spread over a considerable surface in consequence of the chorion villi 
entering into communication with a larger portion of the decidua than 
usual {placenta membranacea). Such forms, however, are merely of 

1 3fonat. /. Geburf., May, 1865. 

2 Priestley, The Pathology of Intra-uterine Death, p. 156. 



PATHOLOGY OF THE DECIDIJA AND OVUM. 



235 



scientific interest. The only anomaly of shape of any practical import- 
ance is the formation of what have been called placenta saceenfMrice. 
These consist of one or more separate masses of placental tissue, pro- 
duced by the development of isolated patches of chorion villi. Hohl 
believes that they always form exactly at the junction of the anterior 



Fig. 91 




Myxoma Fibrosum of the Placenta. (After Storch.) 

and posterior walls of the uterus, which in early pregnancy is a mere 
line. As the uterus expands the portions of placenta on each side of 
this become separated from each other. They are only of consequence 
from the possibility of their remaining unnoticed in the uterus after 
delivery and giving rise to secondary post-partum hemorrhage. The 
rare form of double placenta with a single cord figured in the accom- 
panying woodcut (Fig. 92) was probably formed in this way, and 'the 
supplementary portion in such a case might readily escape notice. 

The placenta may also vary in dimensions. Sometimes it is of ex- 
cessive size, generally when the child is unusually big, but not 
unfrequently in connection with hydramnios, the child being dead 
and shrivelled. In other cases it is remarkably small, or at least 
appears to be so. If the child be healthy, this is probably o\' no 
pathological importance, as its smallness may be more apparent than 
real, depending on its vessels not being distended with blood. A\'Iumi 
true atro{)hy of the placenta exists, the vitality of the fivtus may be 
seriously interfered with. This condition may depenil either on a 
diseased state of the chorion villi ov of the decidna in Mhich tluy 
are implanted.^ The latter is the more common oi' the two; and it 
generally consists in hyperplasia oi' the connective tissue of thedecidua, 

MVhittakor, Amcr. Jouni. of OhsUi., 1870 71. vol. iii. y. '2':\\ 



236 



PEEGXAyCY, 



wliicli presses on the villi aud vessels and gives rise to general or local 
atrophy. The change is similar in its nature to that observed in 
cirrhosis of the liver and certain forms of Bright's disease. It has 
been specially studied by Heger and Miiier/ who describe it as begin- 
ning with a development of the elongated fusiform cells of the decidua, 
accompanied by an increase of the intercellular granular material. 
Eventually the cells undergo fatty degeneration and the whole struc- 

FiG. 92. 




Double I'lacenta, with single cord. 



ture becomes fibroid. This has generally been ascribed to inflamma- 
tory changes, and under the name of jjlaeentitis has been described by 
many authors, and has been considered to be a common disease. To it 
are attributed many of the morbid alterations which are commonly 
observed in placent&e, such as hepatizations, circumscribed purulent 
deposits, and adhesions to the uterine walls. Many modern path- 
ologists have doubted whether these changes are in any proper sense 
inflammatory. Whittaker observes on this point: ''The disposition to 
reject placentitis altogether increases in modern times. Indeed, it is im- 
possible to conceive of inflammation on the modern theory (Cohnheim) 
of that process, since there are no capillaries, in the maternal portion at 
least, through whose walls a ' migration ' might occur, and there are no 
nerves to regulate the contractility of the vessel-walls in the entire 
structure." Robin thus explains the various pathological changes 
above alluded to: "A\^hat has been taken for inflammation of the 

^ Virchovjs Archil; 1871. 



PATHOLOGY OF THE DECIDUA AND OVUM. 



237 



placenta is nothing else than a condition of transformation of blood- 
clots at various periods. What has been regarded as pus is only fibrin 
in the course of disorganization, and in those cases where true pus has 
been found the pus did not come from the placenta, but from an inflam- 
mation of the tissue of the uterine vessels and an accidental deposition 
in the tissue of the placenta/^ The extravasations of blood here 
alluded to are of very common occurrence, and they are found in all 
parts of the organ — in its substance, on its decidual surface, or imme- 
diately below the amnion, where they serve as points of origin for the 
cysts that are there often observed. The fibrin thus deposited under- 
goes retrograde metamorphosis as in other parts of the body; it becomes 
decolorized, undergoes fatty degeneration, or becomes changed into cal- 
careous masses; and in this way, it is supposed, may be explained 
the various pathological changes which are so commonly observed. 
The amount of retrograde metamorphosis and the precise appearance 
presented will, of course, depend on the time that has elapsed since the 
blood extravasations took place. 

Fatty deg-eneration of the placenta, and its influence on the 
nutrition of the foetus, have been specially studied in England by 



Fig. 93. 




Fatty Dogoncratidu oi\\\c Plaooma. 

Barnes and Druitt. Yellowish masses of varying sizes are vorv c'oni- 
monly met with in ph\('enta\ and these are found lo consist, in groat 
part, of molecular fat, ;nixed with a fine netwoi'k ot' iibrous tissue. 
The true fatty degeneration, however, specially atVects tlio chorion villi 
(Fig. 93). On micnxsa^pic examination they are found to bo alioiwl 



238 



FBEGNANCY. 



and misshapen in their contour and to be loaded with fine granular fat- 
globules. Similar changes are observed in the cells of the decidua. 
The influence on the foetus will of course depend on the extent to which 
the functions of the villi are interfered with. The probable cause of 
this degeneration is no doubt some obscure alteration in the nutrition of 
the tissue depending on the state of the mother's health. The proba- 
bility is that generally the fatty degeneration is not a primitive change, 
but a stage of some other morbid condition which precedes or is asso- 
ciated Avith it. Barnes believes that syphilis has much influence in its 
2)roduction. Druitt has pointed out that some amount of fatty degen- 
eration is always present in a mature placenta, and is probably connected 
with the physiological separation of the organ ; and Goodell has more 
recently suggested that an unusual amount of this change may be merely 
an anticipation of the natural termination of the life of the placenta.^ 

Other morbid states of the placenta, of greater rarity, are occasionally 
met w^ith, as an oedematous infiltration of its tissue — always occurring, 
according to Lange, in cases of hydramnios — pigmentary and calcareous 
deposits, and tumors of various kinds ; l)ut these require only a passing 
mention. 

Pathology of the Umbilical Cord. — The umbilical cord may be of 
excessive length, varying from 18 to 20 inches, wdiich is its average 
measurement, up to 50 or 60 inches, and a case is recorded in Avhich it 
even reached the extraordinary length of 9 feet. If unusually long it 
may be twisted round the limbs or neck of the child, and the latter 
position may, in exceptional instances, prove injurious during labor. 
Some authors refer eases of spontaneous amputation of foetal limbs in 
utero to constrictions by the umbilical cord, but this accident is more 

probably produced by filamentous adnexa 
of the amnion. Knots in the cord are not 
uncommon, and they result from the foetus 
in its movements passing through a loop 
of the cord (Fig. 94). If there is an aver- 
age amount of Wharton's jelly in the cord, 
the vessels are protected from pressure and 
no bad effects follow. Gery in a recent 
paper on the subject^ attempts to show that 
such knots are more important than is gen- 
erally believed, and relates two cases in 
AV'hich he believes them to have caused the 
death of the foetus. 

Extreme torsion of the cord, an exag- 
geration of the spiral twists generally 
observed, may prove injurious, and even 
fatal, to the child by obstructing the cir- 
culation in the vessels. Spaeth mentions 
three cases in which this caused the death 
of the foetus, the cord being twisted until 
it was reduced to the thickness of a thread. 
[I have in my possession a very remark- 
1 Am. Journ. ObsteL, 1869-70, vol. ii. p. 535. ^ j^ > jj^Iq^ medicale, Oct., 1876. 



Fig. 94. 




Knots of the Umbilical Cord. 



ICU.S 

ill If 



PATHOLOGY OF THE DECWUA ANJJ OVUM. 239 

able funis which I exhibited before the Pathological Society of Phila- 
delphia thirty years ago, the day after its removal from a primipara, 
who gave birth to a strong male fcjetus. The entire cord from umljil" 
to placenta was twisted in the form of a helix, the turns number 
between thirty and forty, very regularly arranged, and constituting a 
cylinder of about f of an inch in diameter — long enough to reach from 
the umbilicus to the shoulder of the child, around the back of the neck, 
down over its abdomen, and to the placenta, which was firmly attached 
within the uterus after the foetus was expelled. The cord, irrespective 
of its twist, was of full average length, and did not appear to offer any 
appreciable obstacle to the flow of blood. — Ed.] 

Anomalies in the distribution of the vessels of the cord are of common 
occurrence. The cord may be attached to the edge instead of to the 
centre of the placenta (battledore placenta). It may break up into its 
component parts before reaching the placenta, the vessels running 
through the membranes ; and if, in such a case, traction on the cord Ije 
made, the separate vessels may lacerate and the cord become detached. 
There may be two veins and one artery, or only one vein and one 
artery, or there may be two separate cords to one placenta. These 
and other anomalies that might be mentioned are of little practical 
importance. 

Pathology of the Amnion. — The principal pathological condition 
of the amnion with which we are acquainted is that which is associated 
with excessive secretion of liquor amnii, and is generally known under 
the name of hydramnios ; which term Kidd ^ limits to cases in which 
more than two quarts of amniotic fluid exist. Its precise cause is still a 
matter of doubt. By some it is referred to inflammation of the amnion 
itself; at other times it is apparently connected with some morbid state 
of the decidua, which may be found diseased and hypertrophied. The 
foetus is very often dead and shrivelled and the placenta enlarged and 
^edematous. It does not necessarily follow, however, that hydramnios 
causes the death of the child. Out of 33 cases McClintock found tluit 
9 children were born dead;^ and of the 24 born alive, 10 died within 
a few hours ; the remainder survived. There does not appear to be any 
marked relation between the state of the mother's health and the occur- 
rence of this disease ; and it is certainly not necessarily present when 
the mother is suffering from dropsical eflusions in other parts of the 
body. The theory that the disease is of purely local origin is favored 
by the fact that when hydramnios occurs in twin pregnancy, one ovum 
only is generally affected. Its effects, as regards the mother, are chiefly 
mechanical. It rarely begins to show itself before the fifth or sixth 
month of pregnancy, but when once it has commenced it rapidly pnv 
duces a feeling of discomfort and enlargement altogether beyond tiiat 
which should exist at the period of pregnancy which has been reached. 
In advanced stages the distress })roduced is often very great, the enlarged 
uterus pressing upon i\\o dia})hragm and producing much embarrassment 
of respiration. Premature expulsion of the fa^tus very often supervenes. 

^ "On the Diagnosis ot" Drbpsy of the Amnion." Pvocccdinqs of the Obstetrical SocU'ty 
of Dublin, May 11. 1878. 
'■* Diseases of Women, p. 383. 



240 PREGNANCY. 

Four out of McClintock's patients died after labor, showing that the 
maternal mortality is high — a result which he refers to the debilitated 
state of the women who were the subjects of the disease. 

\_Hychamnios is a true cystic dropsy of the amniotic sac, and, although 
due to ditferent causes, is in the worst cases the result of obstruction in 
the placento-foetal circuit of blood-vessels, and mainly in the liver or 
heart of the foetus. The amnion has the anatomical features of a 
secreting membrane, and is capable of endosmosis and exosmosis, the 
latter of Avhich is notably exhibited in the removal of liquor amnii after 
foetal death in an ectopic pregnancy. When from any cause the circu- 
lation of blood is impeded in the foetus, and the placenta still keeps up 
its functional activity, the disparity between placental supply and foetal 
requirement will produce a dropsical effusion as the result of the 
mechanical obstruction ; hence the large proportion of deaths in the foe- 
tus in cases of hydramnios. — Ed.] 

Diag-nosis. — The diagnosis is not, as a rule, difficult. It has to be 
distinguished from ascitic distension of the abdomen, from enlargement 
of the uterus from twin pregnancy, and from ovarian tumor or preg- 
nancy complicated with ovarian tumor. The first will be recognized by 
the superficial position of the fluid ; the difficulty of feeling the contour 
of the uterus, which is obscured by the surrounding fluid, and the results 
of percussion, which show that the fluid is free in the peritoneal cavity; 
and by the coexistence of dropsical effusions in other parts of the body. 
The second may be difficult, and even impossible, to diagnose from it ; 
generally, however, in hydramnios the uterine tumor is more distinctly 
tense or fluctuating, the foetal limbs cannot be felt on palpation, and the 
lower segment of the uterus, as fe\t jper vaginam, is unusually distended, 
the presenting part not being appreciable. Ovarian tumors alone or 
complicating pregnancy may also be difficult to distinguish from dropsy 
of the amnion. The general history of the case and the presence or 
absence of signs of pregnancy may enable us to arrive at a diagnosis ; 
and Kidd points out that the position of the uterus, Avhether gravid or 
not, is usually low down in the pelvis in ovarian dropsy, while in 
dropsy of the amnion it is drawn high up and reached with difficulty 
on vaginal examination. 

During labor an excessive amount of liquor amnii is often a cause of 
deficient uterine action and delay, the pains being feeble and ineffective. 
This, of course, tells chiefly in the first stage, which is often much pro- 
longed, unless the membranes are punctured early and the superabun- 
dant fluid allowed to escape. 

Treatment. — No treatment is known to have any effect on the dis- 
ease. If the discomfort and distension are very great, it may be abso- 
lutely necessary to puncture the membranes and allow the water to 
escape. This inevitably brings on labor. If the pregnancy be not 
sufficiently advanced to give hope for the birth of a living child, we 
would not, of course, resort to this expedient unless the mother's health 
was seriously imperilled. It is possible that in such cases the patient 
might be relieved by inserting the minute needle of an aspirator 
through the os and removing a certain quantity of the liquor amnii 



PATHOLOGY OF THE DECTDUA AND OVUM. 241 

by aspiration, witliout inducing the labor. I have never liacl an oppor- 
tunity of trying this expedient, but it seems a possibility. 

Deficiency of Liquor Amnii. — A defective amount of liquor aninii 
is said to favor certain malformations, by allowing the uterus to com- 
press the foetus unduly. It certainly occasionally gives rise to adhesion 
between the foetus and the membranes, and to the formation of amniotic 
bands which are capable of producing certain foetal deformities (pp. 2o^ 
and 244). 

The liquor amnii itself varies much in appearance. It is sometimes 
thick and treacly, instead of limpid, and it may be offensive in odor. 
The cause of these variations is not well understood. 

Pathology of the Foetus. — There is abundant evidence that the 
foetus in utero is subject to many diseases, some of which cause its 
death, and others leave distinct traces of their existence, although not 
proving fatal. The subject is of great importance, and is well worthy 
of study. There is still much to be done in this direction, which may 
lead to important practical results. I can, however, do little more 
than enumerate some of the principal affections which have been 
observed. 

Diseases Transmitted through the Mother. — It is a w^ell-estab- 
lished fact that the various eruptive fevers from which the mother may 
suffer may be communicated to the foetus in utero. When the mother 
is attacked with confluent small-pox she almost always aborts, but not 
necessarily so when it is discrete or modified. In such cases it has often 
happened that the foetus has been born with evident marks of small- 
pox. Cases are on record which prove that the foetus was attacked 
subsequently to the mother. Thus, a mother attacked with small-pox 
has miscarried, and has given birth to a living child showing no trace of 
the disease, which, however, showed itself in tw^o or three days; proving 
that it had been contracted and had run through its usual period of in- 
cubation when the foetus was still in utero. It does not follow, however, 
that the foetus is affected, as Serres has collected 22 cases in which women 
suffering from small-pox gave birth to children who had not contracted 
the disease. It has been supposed that in such cases the child is pro- 
tected from small-pox, though it has shown no symptom of having had 
the disease. Tarnier, how^ever, cites two instances in which such chil- 
dren had small-pox two years after birth. ^ladgc and Simpson record 
cases in which vaccination performed on the mother during pregnancy 
protected the foetus, on whom all subsequent attempts at vaccination 
failed. There is evidence also to prove that the disease may be trans- 
mitted to the foetus through a mother who is lun-solf unsusceptible ot* 
contagion, the child having been covered with small-pox eruption, the 
mother being quite free from it. It is probable that the same facts 
which have been observed Avith regard to small-pox hold true with 
reference to other zymotic diseases, such as scarlet fever and measles, 
although there is not sufficient evidence to justity a jiositive asser- 
tion to that effect. 

Amongst other maternal diseases, malaiia and K>ad-{)oisoning are 
known to ailect the fix^tus in utero. Or. Stokes relates cases in whic^h 
the mother sullered from tertian ague, the child having alst^ attacks, as 



242 PREGNANCY. 

evidenced by its convulsive movements, appi'eciable by the mother, 
which took place at the regular intervals, but at a diffei-ent time from 
the mother's paroxysms. In other cases the febrile paroxysm comes on 
at the same time in the foetus as in the mother ; and the fact has been 
verified by the observation that the paroxysms continued to recur 
simultaneously after delivery. The foetus has also been born Avith dis- 
tinct malarious enlargement of the spleen. From the frequency with 
Avhich largely hypertrophied spleens are seen in mere infants in mala- 
rious districts I imagine that the intra-uterine disease must be common. 
I have frequently observed this fact in India, although, of course, Avith- 
out any possibility of ascertaining if the mothers had suffered from 
intermittent fever during pregnancy. Lead-poisoning is also known to 
have a most prejudicial effect on the foetus, and frequently to lead to 
abortion. M. Paul has collected 81 cases ^ in which it caused the death 
of the foetus, in some not until after birth ; and occasionally it seems to 
have affected the foetus even when the mother escaped. 

Of all blood-dyscrasise transmitted to the foetus, the most important 
is syphilis. Its influence in producing repeated abortion is elsewhere 
described (p. 251). It may unquestionably be transmitted to the foetus 
Avithout producing abortion, and at term the mother may be either 
delivered of a living child bearing evident traces of the disease, of 
a dead child similarly affected, or of an apparently healthy child in 
whom the disease develops itself after a lapse of a month or tAvo. 
These varying effects probably depend on the intensity of the poison ; 
and the longer the time has elapsed since the origin of the disease in 
the affected parent the better will be the chance for the child. The 
disease is no doubt generally transmitted through the mother, and if she 
be affected at the time of conception the infection of the foetus seems 
certain. If, hoAvever, she contracts the disease at an advanced period 
of pregnancy, the child may entirely escape. Kicord even believes that 
syphilis contracted after the sixth month of pregnancy never affects the 
child. The father alone may transmit the disease to the ovum ; and 
Hutchinson has recorded cases to shoAV that the mother may become 
secondarily affected through the diseased foetus. The evidences of 
syphilitic taint in a living or dead child are sufficiently characteristic. 
The child is generally puny and ill-developed. An eruption of 
pemphigus is common — either fully-developed bullae or their early 
stage, Avhen they form circular copper-colored patches. This eruption 
is ahvays most marked on the hands and feet, and a child born with 
such an eruption may be certainly considered syphilitic. On post- 
mortem examination the most usual signs are small patches of suppura- 
tion in the thymus, similar localized suppurations in the tissues of the 
lungs, indurated yelloAvish patches in the liver, and peritonitis, the im- 
portance of AAdiich in causing the death of syphilitic children has been 
specially dAvelt on by Simpson.- 

The most important of the inflammatory diseases affecting the foetus 
is peritonitis. Simpson has shown that traces of it are very frequently 
met Avith, and tliat it is not ahvays syphilitic. Sometimes it has been 
obserA^ed Avhen tlie mothei- has been in bad health during pregnancy, 

1 Arch. gen. ch Med., 1800. ' Obst. Worl'>^, vol. i. p. 117. 



PATJIOLOar OF THE UECWUA AND OVUM. 243 

and at others it seems to have resulted from some riKjj-bid eondition of 
the foetal viscera. Pleurisy with effusion is another inflammatory affec- 
tion which has been noticed. 

The dropsical affections most generally met with are ascites and 
hydrocephalus, which may both have the effect of impeding delivery. 
Of these, hydrocephalus is the more common, and may give rise to 
much difficulty in labor. Its causes are uncertain, but it probably de- 
pends <3n some altered state of the mother's health, as it is apt to recur 
in several successive pregnancies, and is not infrequently associated with 
an imperfectly-developed vertebral column and spina bifida. The fluid 
collects in the ventricles, which it greatly distends, and these then pr<j- 
duce expansion and thinning of the cranium, the bones of which are 
widely separated from each other at the sutures, which are prominent 
and fluctuating. In a few cases internal hydrocephalus may be com- 
plicated, and the diagnosis in labor consequently obscured by the coex- 
istence of what has been called ^'external hydrocephalus." This con- 
sists of a collection of fluid between* the skull and the scalp, which may 
be either formed there originally or may collect from a rupture of one 
of the sutures or fontanelles during labor, through which the intracranial 
fluid escapes. 

Ascites is generally associated with hydramnios, and sometimes with 
hydrothorax or other dropsical effusions. It is a rare affection, and 
according to Depaul ^ extreme distension of the bladder is not infre- 
quently mistaken for it. 

Tumors of different kinds may be met with in various parts of the 
child's body, which sometimes grow to a great size and impede delivery. 
Tarnier records cases of meningocele larger than a child's head, and 
large cystic growths have been observed attached to the nates, pectoral 
region, or other parts of the body. Cancerous tumors of considerable 
size, either external or of the viscera, have also been met with. Other 
foetal tumors may be produced by congenital deformities, such as projec- 
tion of the liver or other abdominal viscera through a deficiency of the 
al)dominal wall ; or spina bifida from imperfectly-developed vertebrae. 
The amount of dystocia produced by such causes will, of course, vary 
much in proportion to the size, consistency, and accessibility of the 
tumor. 

Wounds and Injuries of the Foetus. — ^^Accidents of serious gravity 
to the ffetus may ha])pen from violence to which the mother has been 
subjected, such as falls or blows, without necessarily interfering with 
gestation. Many curious examples of this kind are on record. Thus, a 
child has been born presenting a severe lacerated wound extending the 
wliole length of the spine, where both the skin and the nuiscles have 
been torn, and which seems to have resulted Irom the mother having 
fallen in the last month of pregnancy. Similar lacerations and contu- 
sions have been observed in other parts of the body, the wounds being 
in various stages of cicatrization corresponding to the lap>eol' tiniesinre 
th(* accident had occiUTcd. Intra-uterine fractures inv not rnre, aj^par- 
ently arising from simihu* causes. In some of these cases the broktMi 
ends of the bones liad iniitcMl, but, from want of at'cin-atc apposition, at 

' 'r:\niior's (\(:<(tiix, p. 855. 



244 



PREGNANCY. 



Fig. 95. 



an acute angle, so as to give rise to much subsequent deformity. 
Chaussier records two cases in which there were many fractures in the 
same child — in one 113, and in another 42 — which were in different 
stages of repair. He attributes this curious occurrence to some con- 
genital defect in the nutrition of the bones, possibly allied to mollities 
ossium.' 

Intra-uterine amputations of foetal limbs have not unfrequently been 
observed. Children are occasionally born with one extremity more or 

less completely absent, and cases are known 
in Avhich the whole four extremities were 
wanting (Fig. 95). The mode in which these 
malformations are produced has given rise to 
much discussion. At one time it was sup- 
posed that the deficiency of the limb Avas due 
to gangrene of the extremity and subsequent 
separation of the sphacelated parts. Reuss, 
who has studied the whole subject very 
minutely,^ considers gangrene in the unrup- 
tured ovum to be an impossibility, for that 
change cannot occur unless there is access of 
oxygen ; and when portions of the separated 
extremity are found in idero, as is often the 
case, they show evidences of maceration, but 
not of decomposition. The general belief is 
that these intra-uterine amputations depend 
on constriction of the limb by folds or bands 
of the amnion — most often met with . when 
the liquor amnii is deficient in quantity — 
which obstruct the circulation and thus give rise to atrophy of the part 
below the constriction. It has been supposed that the umbilical cord 
might, by encircling the limb, produce a like result. It appears doubt- 
ful, however, whether this cause is sufficient to produce complete sepa- 
ration of the limb, as any great amount of constriction would interfere 
with the circulation through the cord. Sometimes, when intra-uterine 
amputation occurs, the separated portion of the limb is found lying loose 
in the amniotic cavity, and is expelled after the child. Cases of this kind 
have been recorded by Martin, Chaussier, and Watkinson. More often 
no trace of the separated extremity can be found. The explanation 
probably depends upon the period of utero-gestation at which amputa- 
tion took place. If it occurred at a very early period of pregnancy, 
before the third month, the detached portion would be minute and soft 
and would easily disappear by solution. If at a later period, this 
could hardly happen and the detached portion would remain in utero. 
In cases of the latter kind cicatrization of the stump has often been 
observed to be incomplete. Simpson pointed out the occasional exist- 
ence of rudimentary fingers or toes on the stump of an amputated limb, 
such as are seen on the thighs in Fig. 95. These he attributed to an 
abortive reproduction of the separated extremity, analogous to what is 
observed in some of the lower animals. This explanation has been con- 

^ Gazette hebdom., 1860. ^ Scanzoni's Beitrage, 1869. 




Intra-uterine Amputation 
both Arms and Legs. 



PATHOLOGY OF THE DKCWIJA AND OVUM. '2Ah 

tested witli much show of reason. Martin l)elieves tliat tlie rqjrodue- 
tion is only apparent, and that the rudimentary extremities are, in 
reality, instances of arrested development. The constricting agents 
interfered with the circulation sufficiently to arrest the growth of the 
limb below the site of constriction, but not sufficiently to effect complete 
separation. If constriction occurred at a very early stage of develop- 
ment, an appearance similar to that observed by Simpson would be pro- 
duced. It does not follow, however, that all cases of absence of 
limbs depend on intra-uterine amputations. In some cases they would 
appear to be the result of a spontaneous arrest of development or of con- 
genital monstrosity. Mr. Scott * relates a case in which a distinct 
hereditary tendency was evident; and here the deformity certainly 
could not have resulted from the constriction of amniotic bands. In 
this family the grandfather had both forearms wanting, with rudi- 
mentary fingers attached ; the next generation escaped, but the grand- 
child had a deformity precisely similar to the grandfather. 

[Arrested PuUulation. — The absence of a hand where there are ru- 
dimentary evidences of an attempt to form the thumb and fingers can 
be accounted for much more satisfactorily on the theory of an arrested 
development taking place in the latter half of the second month of 
embryonic life than upon the hypothetical idea that there has been first 
an amputation in utero, and then an attempt of nature to reproduce the 
lost digits by a new budding process, as taught by Simpson and Annan- 
dale. More than thirty years ago I became fully satisfied that there 
was an inclination in nature to repeat itself so exactly during the pullu- 
lative period of embryonic growth that cases of congenital deficiency of 
the thumb and fingers of a precisely similar character must from time 
to time present themselves to the eye of the medical observer. It so 
happened that three such typical cases, all exactly alike, in two boys and 
one girl, each being strangely without the left hand, came under my 
notice during a short period of years. The forearm in each ended in a 
well-rounded and slightly-flattened stump, from which protruded a row 
of pisiform nailless bodies re2)resenting the embryonic commencement of 
the formation of a thumb and four fingers. I saw these subjects at 
different ages of infancy and childhood, and the little pea-like bodies 
remained the same, with the exception that they became slightly larger. 
In a fourth case, a boy, the finger-rudiments were entirely absent, and 
there was an attempt to form a thumb, which was useless and about 
three-quarters of an inch long: the boy developed into a powerful man 
of six feet. Cases of the precise type of the three first named have ci^ne 
under the observation of medical friends. — Ei\] 

Death of Foetus. — When from any cause the fcvtus has died during 
])regnancy, it may be either soon expelled, or it may be retained in iifo-o 
for a long(H- or shorter time or even to the I'ull period. Tlie changes 
observed in such f(X>tuses vary considerably aecHnnling to the age of the 
fetus at the time of death or the time that it has be^ retained in iifcro. 
If it die at an early ])eri(Hl, when the tissues are very soft, it nuiy entirely 
dissolve in the li(|uor M,mnii, and no trace of it mav he I'ound when the 
membi-nnes ;ir(^ (^xpc^lUnl. Or it may shrivel ov inuininity ; and it' liiis 

' Olh^t. Tntns., IST'J, vol. xiii. [>. !> t. 



246 PEEGNA^^CY. 

happen in a twin pregnancy, as sometimes occurs, the growing fcetus 
may compress and flatten the dead one against the uterine wall. 

At a later period of pregnancy a dead foetus undergoes changes 
ascribed to putrefaction, but which produce appearances different from 
those of decomposition in animal textures exposed to the atmosphere. 
There is no offensive smell, as in ordinary decay. The tissues are all 
softened and flaccid. The more manifest changes are in the skin, the 
epidermis of which is separated from the cutis vera, which has a deep 
reddish color. This is especially apparent on the abdomen, which is 
flaccid, and hollow in the centre. The internal organs are much 
altered. The brain is diffluent and pulpy, and the cranial bones loose 
within the scalp. The structures of the muscles and viscera are in 
various stages of transformation, many having undergone fatty changes, 
and contain crystals of margarin and cholesterin. The extent to which 
these changes occur depends, in a great measure, on the length of time 
the foetus has been dead, but they do not admit of our estimating with 
any degree of accuracy what that time has been. 

The symptoms and diagnosis of the death of the foetus may here 
be considered. They are, unfortunately, not very reliable. The cessa- 
tion of the foetal movements cannot be depended on, as they are fre- 
quently unfelt for days or weeks when the child is alive and well. 
Sometimes the death of the foetus is preceded by its irregular and 
tumultuous movements, and in women who have been delivered of 
several dead children in succession this sensation may guide us in our 
diagnosis. This suspicion may be confirmed by auscultation. The 
mere fact that we are unable at any given time to hear the foetal heart 
will not justify an opinion that the foetus is dead. If, however, the 
foetal heart has been distinctly heard, and after one or two careful 
examinations, repeated at separate times, it cannot again be made out, 
the probability of the child being dead may be assumed. Certain 
changes in the mother's health have been noted in connection with the 
death of the foetus, such as depression and lowness of spirits, a feeling 
of coldness and weight about the lower parts of the abdomen, paleness 
of the face, a livid circle round the eyes, irregular shiverings and fever- 
ishness, shrinking of the breasts, and diminution in the size of the 
abdominal tumor. All these, how^ever, are too indefinite to justify 
a positive diagnosis, and they are not infrequently altogether absent. 
At most they can do no more than cause a suspicion as to w^hat 
has happened. 



ABORTION AND PREMATURE LABOR. 24" 



CHAPTER X. 

ABORTION AND PREMATURE LABOR. 

Importance and Frequency of Abortion. — Tlie premature expul- 
sion of the foetus is an event of great frequency. The number of 
foetal lives thus lost is enormous. There are few multiparte who have 
not aborted at one time or other of their lives. Heger estimates that 
about 1 abortion occurs to every 8 or 10 deliveries at term. White- 
head has calculated that at least 90 per cent, of married women who 
lived to the change of life had aborted. The influence of this inci- 
dent on the future health of the mother is also of great importance. 
It rarely, indeed, proves directly fatal, but it often produces great debil- 
ity from the profuse loss of blood accompanying it ; and it is one of 
the most prolific causes of uterine disease in after-life, possibly because 
women are apt to be more careless during convalescence than after 
delivery, and the proper involution of the uterus is thus more fre- 
quently interfered with. 

Definition. — A not uncommon division of the subject is into abor- 
tion, miscarriage, and premature labor, the first name being applied to 
expulsion of the ovum before the end of the fourth month of utero- 
gestation ; miscarriage, to expulsion from the end of the fourth to the 
end of the sixth month ; and premature labor, to expulsion from the 
end of the sixth month to the term of pregnancy. This is, however, a 
needless and confusing subdivision which leads to no practical result. 
It suffices to apply the term " abortion '' or ^' miscarriage " indiscrim- 
inately to all cases in which pregnancy is terminated before the foetus 
has arrived at a viable age, and " premature labor " to those in which 
there is a possibility of its survival. There is little or no hope of a 
foetus living before the twenty-eighth week, or seventh lunar month, 
and this period is therefore generally fixed on as the limit between 
premature labor and abortion. The rule is, however, not without an 
occasional, although very rare, exception. Dr. Iveiller of Edinburgh 
has recorded an instance in which a fcrtus was born alive at the fourth 
month, nine days after* the mother had experienced the sensiition of 
quickening. I myself recently attended a lady who miscarried in the, 
fifth month of pregnancy, the child being born alive and living for 
three hours. Several cases are on record in which after delivery in the 
sixth month the child survived and was reared. The possibility of the 
birth of a living child under such circumstances should be recognized, 
as it may give rise to legal questions of importance ; but the exceptions 
to the ordinary rule are so rare that they \u\\\ not intort\>re with the 
division of the subject usually made. 

Abortion is most Common in Multiparas. — ^rnltipar;e abort tar 
more fre(]uently than primipara\ This is contrary to the statement in 
many obstetrical works. Thus, Tyler Smith Siivs " there seems to be a 



248 PREGNANCY. 



greater clanger of this accident in the first pregnancy/' Schroeder/ 
howeverj states that 23 muhiparse abort to 3 primiparse ; and Dr. 
Whitehead of Manchester, who has particularly studied the subject, 
believes that abortion is more apt to occur after the third and fourth 
pregnancies, especially Avhen these take place toward the time for the 
cessation of menstruation. 

There can be no doubt that women who have aborted more than once 
are peculiarly liable to a recurrence of the accident. This can generally 
be traced to the existence of some predisposing cause which persists 
through several pregnancies ; as, for example, a syphilitic taint, a ute- 
rine flexion, or a morbid state of the lining membrane of the uterus. 
It is probable that in many women a recurrence of the accident induces 
a habit of abortion, or perhaps it might be more accurate to say a pecu- 
liar irritable condition of the uterus, which renders the continuance of 
pregnancy a matter of difficulty independently of any recognizable 
organic cause. 

The frequency of abortion varies much at different periods of preg- 
nancy, and it occurs much more often in the early months, because of 
the comparatively slight connection then existing betAveen the chorion 
and the decidua. At a very early period of pregnancy the ovum is cast 
off with such facility, and is of such minute size, that the fact of abor- 
tion having occurred passes unrecognized. Very many cases in which 
the patient goes one or two weeks over her time, and then has what is 
supposed to be merely a more than usually profuse period, are probably 
instances of such early miscarriages. Velpeau detected an ovum of 
about fourteen days which was not larger than an ordinary pea, and it is 
easy to understand how so small a body should pass unnoticed in tlie 
blood which escapes along with it. 

Up to the end of the third month, when miscarriage occurs, the ovum 
is generally cast off en masse, the clecidua subsequently coming away in 
shreds or as an entire membrane. The abortion is then comparatively 
easy. From the third to the sixth month, after the placenta is formed, 
the amnion is, as a rule, first ruptured by the uterine contractions and 
the foetus is expelled by itself. The placenta and membranes may then 
be shed as in ordinary labor. It often happens, however, that on 
account of the firmness of the placental adhesion at this period the 
secundines are retained for a greater or less length of time. This sub- 
jects the patient to many risks, especially to those of profuse hemor- 
rhage and of septicaemia. For this reason premature termination of 
the pregnancy is attended by much greater danger to the mother between 
the third and sixth months than at an earlier or later date. After the 
sixth month the course of events is not different from that attending 
ordinary labor. The prognosis to the child is more unfavorable in pro- 
])ortion to the distance from the full period of gestation at which 
premature labor takes place. 

Causes. — The causes of abortion may conveniently be subdivided 
into the predisposing and excitincj, the latter being often slight, and such 
as would have no effect in inducing uterine contractions in women 
unless associated with one or more of tlie former class of causes. The 

^ Schroeder, Manual of Midwifery, p. 149. 



ABORTION AND PREMATURE LABOR. 249 

predisposition to abortion may depend on some eoiidition interfering 
with the vitality of the ovum or its relation to the maternal sti'uetnres, 
or on certain conditions directly affecting the mother's health. 

One of the most common antecedents of abortion is the death of the 
foetus, which leads to secondary changes and ultimately produces the 
uterine contractions which end in its expulsion. The precise causes of 
death in any given case cannot always be accurately ascertained, as they 
sometimes depend on conditions which are traceable to the maternal 
structures, at others to the ovular, or, it may be, to a combination of 
the two. Nor does it by any means follow that the death of the ovum 
immediately results in its expulsion. The mode in which death of the 
ovum produces abortion is not difficult to understand, for it necessarily 
leads to changes in the relations between the ovular and maternal struc- 
tures : these changes cause hemorrhages — partly external and partly 
into the membranes — which in their turn excite uterine contraction. 
Extravasations of blood may take place in various positions. One of 
the most common is into the decidual cavity, between the decidua vera 
and the decidua reflexa, or between the decidua vera and the uterine 
walls. If the hemorrhage is only slight, and especially if it comes 
from that portion of the decidua near the internal os and at a distance 
from the ovum, there need be no material separation and pregnancy 
may continue. This explains the cases occasionally met with in which 
there is more or less hemorrhage without subsequent abortion. Wheu 




An Apoplectic Ovum, with blood ort\isod in masses uiuler the tVvtal surface of the luem- 

bnincs. 

tlie amount of extravasated blood is at all gretit, sc]xn';ition and abor- 
tion necessarily result, and the decidua will be found c^n i^xpnKion to 



250 PREGNANCY. 

ha\e coagula on its surface and between its various layers, which are 
found to project into the cavity of the amnion (Fig. 96). In other 
cases hemorrhage is still more extensive, and, after breaking through 
tlie decidua reilexa, forms clots between it and the chorion, and even in 
the cavity of the amnion. Supposing expulsion to take place shortly 
after coagula are deposited among the membranes, the blood is little 
altered and we have an ordinary abortion. If, however, the ovum is 
retained, the coagulated fibrin and the placenta or membranes undergo 
secondary changes which lead to tlie formation of moles. The so-called 
Jieshy mole (Fig. 97) is often retained for many weeks or months after 

Fm. 97. 




Blighted Ovum, with fleshy degeneration of the membranes. 

the death of the foetus, and during this time there may be but little 
modification of the usual symptoms of pregnancy ; or, as is frequently 
the case, it gives rise to occasional hemorrhage, until at last uterine con- 
tractions come on, and it is cast off in the form of a thick fleshy mass 
having but little resemblance to the ordinary products of conception. 
The most probable explanation of its formation is that Avhen hemor- 
rhage originally took place the effusion of blood was not sufficient to 
effect the entire separation and expulsion of the ovum. Part of the 
membranes or of the placenta — if that organ had commenced to form 
— retained its organic connection with the uterus, while the foetus per- 
ished. The attached portion of the placenta or membranes continues 
to be nourished, although abnormally. The foetus generally entirely 
disappears, especially if it has perished at an early period of utero-ges- 
tation, Avhen it becomes dissolved in the liquor amnii ; or it may 
become macerated, shrivelled, and greatly altered in appearance. The 
effused blood becomes decolorized from the absorption of the corpus- 
cles, and, according to Scanzoni, fresh vessels are develo])ed in the fibrin, 
which increase the vascular attachment of the mole to the uterine walls. 



ABORTION AND PREMATURE LABOR. 2ol 

The placenta and membranes may go on increasing in thickness until 
they form a mass of considerable size. Careful micnjscopic examina- 
tion will almost always enable us to discover the villi of the chorion, 
altered in appearance, often loaded with granular fatty molecules, but 
sufficiently distinct to be readily recognizable. 

Important as are the causes of abortion arising from some morbid 
condition of the ovum, they are not more so than those which depend 
on the maternal state; and it is to be observed that the former are often 
indirect causes produced by primary maternal changes. Many of these 
maternal causes act by causing hyperaemia of the uterus, which leads 
to extravasation of blood. Thus, abortion is apt to occur in women 
who lead unhealthy lives, such as those who occupy overheated and ill- 
ventilated rooms, or indulge to excess in the fatigues and pleasures of 
society, in the use of alcoholic drinks, and the like. Over-frequent 
coitus has been, for the same reason, observed to produce a remarkable 
tendency to abortion, and Parent-Duchatelet has noted that it is of veiy 
frequent occurrence amongst women of loose life. Many diseases 
strongly predispose to it, such as fevers, zymotic diseases of all kinds, 
measles, scarlet fever, small-pox, and diseases of the respiratory organs, 
such as bronchitis and pneumonia. Syphilis is well known to be one 
of the most frequent causes, and one that is likely to act in successive 
pregnancies. It may act so that the pregnancy is brought to a prema- 
ture termination, time after time, until the constitutional disease is 
eradicated by appropriate treatment. It acts in some cases through the 
influence of the father in producing a diseased ovum ; and it is the 
only cause wdiicli can with certainty be traced to the state of the father's 
health. Many other morbid conditions of the blood also dispose to 
abortion. It has been observed to be a frequent result of lead-poison- 
ing, also of the presence of noxious gases in the atmosphere, such as au 
excess of carbonic acid. 

Many causes act through the nervous system, such as fright, anxiety, 
sudden shock, and the like. Thus there are numerous instances on 
record in which women aborted suddenly after the receipt of some bad 
news, and it is said to have been of frequent occurrence in women 
immediately before execution. The influence of irritation propagated 
through the nervous system from a distance, tending to produce uterine 
contraction and abortion through the agency of reflex action, lias been 
specially dwelt upon by Tyler Smith. Thus he points out that abor- 
tion not unfrequently occurs from the irritation of constant suckling in 
women who become pregnant during lactation. The eflect of suckling 
in ])roducing uterine contraction is, indeed, Avell known, and the appli- 
cation of the child to the breast for this jnu'pose has long been rcc(\i:- 
nized as a method of treatment in post-partum henuM-rhage. The 
irritation of the trifacial in severe toothaclu*; of the renal nerves in 
cases of gravel, in albuminuria, etc.; of the intestinal nerves in exces- 
sive vomiting, in diarrlnea, obstinate constipation, ascarides, eti\, — acts 
in the same way. We may ])erhaps also explain by this hypothesis 
the fact that women are^more apt to abort at what would have been the 
menstrual epoch than at other tinus, as the ovarian nerves may then Ik* 
subject to undue excitement, it is probabli\ however, that there may 



252 PREGNAXCY. 

be also at these times more or less active congestion of the decidua, 
which may predispose to laceration of its capillaries and blood- 
extravasation. Sncii congestion exists in those exceptional cases in 
which menstruation continues for one or more periods after concep- 
tion, the blood probably escaping from the space between the decidua 
vera and reflexa; and therefore there is no reason to question its 
also happening even when such abnormal menstruation is not 
present. 

Certain physical causes may produce abortion by separating the 
ovum. Thus it may follow a fall, a blow, or other accidents of a 
trivial character. On the other hand, women may be subjected to 
injuries of the severest kind without aborting. The probability, 
therefore, is that these apparently trivial causes only operate in 
women who for some other reason are predisposed to the accident. 
This is borne out by the fact — which is well known in these days, 
when the artificial production of abortion is, unhappily, far from a'very 
rare event — that it is by no means easy to destroy the vitality of the 
foetus. I iliyself know of a case in which the uterine sound was passed 
several times into a pregnant uterus without producing abortion, the 
pregnancy proceeding to term. Oldham has related a similar case in 
which he in vain attempted to induce abortion by the sound in a case 
of contracted pelvis; and Duncan has mentioned an instance in which 
an intra-uterine stem pessary was unwittingly introduced and worn for 
some time by a pregnant woman without any bad effect. The fact that 
pregnancy is with difficulty interfered with when there is a healthy re- 
lation betAveeu the ovum and the uterus no doubt explains the disastrous 
effects of criminal abortion which have been especially insisted on by 
many of our American brethren. 

Morbid states of the uterus have an important influence in the pro- 
duction of abortion. Any condition which mechanically interferes with 
the proper development of the uterus is apt to operate in this way. 
Amongst these may be mentioned fibroid tumors; the presence of old 
peritoneal adhesions, rendering the womb a more or less fixed organ; 
but, above all, flexion and displacement of the uterus. Retroflexion of 
the uterus is unquestionably one of the most frequent factors in its 
production, not only on account of the irritation which the abnormal 
position sets up, but from interference with the uterine circulation, 
which leads to the effusion of blood and the death of the ovum. An 
inflamed condition of the cervical and uterine mucous membranes 
will act in the same way should pregnancy have occurred, although 
such a condition more often prevents conception taking place. 

Symptoms. — One of the earliest indications of impending abortion 
is more or less hemorrhage. This may at first be slight, and may last 
for a short time only, recurring after an interval of time, or it may 
commence with a sudden and profuse discharge. Occasionally it is very 
abundant, and its continuance and amount form one of the gravest 
symptoms of the accident. After the loss of blood has continued for a 
greater or less length of time — it may be even for some clays — uterine 
contractions come on, recurring at regular intervals, and eventually 
lead to the expulsion of the ovum. More rarely the impending mis- 



ABORTION AND PREMATURE LABOR. 253 

carriage commences with pains, which lead to laceration of vessels 
and hemorrhage. 

As long as one or other of these symptoms exists alone we may hope 
to avert the threatened miscarriage ; but when both occur together there 
is little or no chance of its being arrested. Certain premonitory symp- 
toms are described by authors as common in abortion, such as feverish- 
ness, shivering, a sensation of coldness; all of which are obscure and 
unreliable, and are certainly much more frequently absent than present. 

If the pregnancy be early it is probable that the entire ovum will 
shed with little trouble, and it often passes unperceived in the clots 
Avhich surround it. It is therefore of importance that all the discharges 
should be very carefully examined. After the second month the rigid 
and undilated cervix presents a formidable obstacle to the escape of the 
ovum, and it may be a considerable time before there is sufficient dila- 
tation to admit of its passage. This is gradually effected by the con- 
tinuance of pains, but not without a severe loss of blood. It may be 
that the amnion is ruptured and the foetus expelled first. After a 
lapse of time the secundines are also shed, but there may be a con- 
siderable delay, amounting even to days, before this is effected. As long 
as any portions of the membranes are retained in utero the patient is nec- 
essarily subjected to considerable risk, not only from the continuance of 
hemorrhage, but also from septicaemia. Hence it may be laid down as 
a rule that we can never consider our patient out of danger until we 
have satisfied ourselves that the whole of the uterine contents have been 
expelled. 

Treatment. — Our first endeavor in any case of impending miscar- 
riage will be, of course, to avert the threatened accident. If hemor- 
rhage has not been excessive, and if, on vaginal examination — which 
should always be practised — we find no dilatation of the os, we may 
entertain a reasonable hope of success. If, on the contrary, we find the 
OS beginning to open, if we are able to insert the finger througli it so as 
to touch the ovum, especially if pains also exist, we are justified in con- 
sidering abortion to be inevitable, and the indication will then be to have 
the ovum expelled and the case terminated as soon as possible. In the 
former case the most absolute rest is the first thing to insist on. The 
patient should be placed in bed, not overburdened with clotlies, in 
a cool temperature, and she should have a light and easily assimi- 
lated diet. All movements, even rising out of bed to empty the 
bladder or bowels, should be absolutely prohibited. To avert the 
tendency to the commencement of uterine contraction there is no 
remedy so useful as opium, which must be given freely and frequently 
repeated. It may be administered either in the form of laudanum 
or of Battley's sedative solution, which has the advantage of produ- 
cing less general disturbance. It may be advantao-eously exhibited in 
doses of from 20 to 30 minims, and repeated after a few liouis. A 
still better preparation is chlorodyne, which 1 have touiul ot' ex- 
treme value in arresting impending miscarriage, in dc^sos ot' 10 
minims, repeated every third or fourth hour. If from any oiaor 
cause it is considered unadvlsable to give the sedative by the mouih, 
it may be administered in a small starch enema per rtvtum. In all 



254 PREGXAXCY. 

eases it will be uecessary to keep the patient more or less under the 
influence of the drug for several days and until all symptoms of 
miscarriage have passed away. [The opiate treatment is sometimes 
marvellously efficient in arresting an active premature labor if used 
early and persevered in. A young multipara belonging to a phthisical 
family once came under my care in labor at four and a half months, the 
uterine contractions coming on at regular intervals, accompanied by pains 
and a considerable loss of blood. Under the use of repeated doses of 
sulphate of morphia her labor-pains weakened, and at the end of ten 
hours ceased entirely, not to return until the full period of gestation was 
accomplished, when I delivered her of a living female child of small 
size, wliicli survived several months. In another case labor was 
checked at eight months and the foetus delivered at the full period. 
— Ed.] Care should be taken that the bowels do not become locked 
up by the action of the opiates — as this might of itself be a cause of 
irritation — and their constipating effects ought to be obviated by small 
doses of castor oil or other gentle aperient. Various subsidiary methods 
of treatment have been recommended, such as bleeding from the arm or 
the local application of leeches in supposed plethoric states of the sys- 
tem ; revulsives, such as dry cupping to the loins ; the application of ice 
to check hemorrhage ; astringents, such as acetate of lead or gallic acid, 
for the same purpose. Most of these, if not hurtful, will be at least 
useless. The cases in which venesection would be beneficial are ex- 
tremely rare, and the local applications, especially cold, are much 
more apt to favor than to prevent uterine action. 

In cases of repeated miscarriage in successive pregnancies a special 
course of prophylactic treatment is indicated, and is often attended with 
much success. In cases of this kind the first indication, and one which 
ought to be carefully attended to, is to seek for and, if possible, to 
remove or mitigate the cause which has given rise to the former abor- 
tions. Those causes which depend on constitutional states must first be 
carefully investigated, and treated according to the indications present. 
These may be obscure and not easily discovered ; but it is certainly 
unwise to assume too readily the existence of what has been called " a 
habit of abortion," which further inquiry may prove to be only an 
indication of constitutional debility, degeneracy of the placental struc- 
tures, or a latent and unsuspected syphilitic taint. If constitutional 
debility be present to a marked extent, a generous diet and a restorative 
course of treatment (preparations of iron, quinine, and other suitable 
tonics) may effect the desired object. 

[The fluid extract of Viburnum prunifolmm is believed by many 
American obstetricians to be of value in cases where there has become 
developed a habit of aborting without any api3arent cause. A change 
of residence to a mountainous region for several months once broke up 
the habit in one of my patients (who was asthmatic and rheumatic) after 
six abortions in the second month, and the child saved has now grown 
up. The mother was of very full habit, and both depletive and opiate 
treatments had signally failed. — Ed.] 

Local congestion of the uterus or a general plethoric state of the 
])atient has often been supposed to be an efficient cause of recurring 



ABORTION AND PRKMATlllK LABOR. 255 

abortion. Dr. Henry Bonnet has OHpeoially dwelt on the influence of 
congestion and abrasions of the cervix in causing premature expulsion 
of the fcetus/ and recommends the topical application of nitrate of silver 
or other caustic to the inflanmiatory abrasions existing on the neck of 
the womb. Formerly venesection was a favorite remedy ; and many 
authors have recommended the local abstraction of blood by leeches 
applied to the groin or round the anus, or even to the cervix. The 
influence of general plethora is more than doubtful ; and, although local 
congestions are probably much more effective causes, still, it would seem 
more judicious to treat them by rest and local sedatives rather than by 
topical applications, which, injudiciously applied, might produce the 
very accident they were intended to prevent. 

The position of the uterus should be carefully investigated. If it be 
found to be retroflexed, a well-fitting Hodge's pessary should be 
applied, so as to support it until it has completely risen out of the 
pelvis. 

The possibility of syphilitic infection should always be inquired into, 
for this poison may act on the product of conception long after all appre- 
ciable traces of it have disappeared from the infected parent. Should 
there be recurrent abortions in a patient who had formerly suffered from 
syphilis or whose husband had at any time contracted the disease, no 
time should be lost in using appropriate antisyphilitic remedies, which 
should invariably be administered both to the husband and wife. Diday 
especially insists that in such cases it is not sufficient to submit the 
father and mother to a mercurial course in the absence of pregnancy, 
but that, as each successive impregnation occurs, the mother should 
again commence antisyphilitic treatment, even though she has no visible 
traces of the disease.^ In this way there is reasonable ground for hoping 
that infection of the ovum may be prevented. I think, too, that we 
may be the more encouraged to persevere in the treatment of these 
unfortunate cases from the fact that the syphilitic poison tends to wear 
itself out. I have seen several cases in which this taint at first pro- 
duced early abortion, then each successive pregnancy was of longer 
duration, until eventually a living chilcl was born. 

In fatty degeneration of the chorion villi and in other morbid states 
of the placenta, which act by preventing the proper nutrition of the 
fa?tus and the due aeration of its blood, there is no relial)lo means of 
treatment except the general improvement of the mother's health. 
Simpson strongly recommended the administration of chlorate of potash 
in cases in which the child habitually dies in the latter months of prog- 
nancy, on the su})position that it supplied to the blood a large amount 
of oxygen, and thus made u}) ibr any dolicioncy in the supply of that 
element through the placental iw'iis. The theory is, at best, a doubitul 
one, although \ believe the drug to be unquestionably bcMieticial in case< 
of the kind. It probably acts l)y its tonic i)roperties rather than in the 
maimer Simpson supposed. It may be given in doses of 15 to 20 
grains three times a day, and may be advantageously combined with 
small doses of dilute hydrochloric aeid. In frecpiently-roctu-ring 

^ On Inihxmmation of the Utcntti, p. 482. 

^ Diday, fiifauh'le SifphiUs, Si/d Soc. Trau^., \\ '107. 



256 PREGNAXCY. 

premature labors with dead children Simpson strongly recommended 
the induction of premature labor a little before the time at which we had 
reason to believe that the foetus had usually perished ; or, in other 
words, before the placental disease had advanced sufficiently far to inter- 
fere with its nutrition. The practice has constantly been adopted Avith 
success, and is perfectly legitimate, but the difficulty, of course, is to fix 
on the right time. Careful auscultation of the foetal heart may be of 
some use in guiding us to a decision, as the death of the foetus is gener- 
ally preceded for some days by irregular, tumultuous, and intermittent 
action of the heart. 

There will always remain a certain number of cases in which no 
appreciable cause can be discovered. Under such circumstances pro- 
longed rest, at least until the time has passed at which abortion formerly 
took place, will affi^rd the best chance of avoiding a recurrence of the 
accident. There must always be some difficulty in carrying out this 
indication, inasmuch as the patient's health is apt to suffer in other ways 
from the confinement and the want of fresh air and exercise which it 
entails. The strictness with which rest should be insisted on must vary 
in different cases, but it should be specially attended to at what would 
have been the menstrual periods, At these times the patient should 
remain in bed altogether ; at others she may lie on a sofa, and, if 
circumstances permit, spend part of the day at least in the open air. 
Sexual intercourse should be prohibited. Should actual symptoms of 
abortion come on, the preventive treatment, already indicated, may be 
resorted to. Great care, however, should be used in prescribing opiates 
as preventives, and they should be given for a specified time only. I 
have seen more than once an incurable habit of opium- eating originate 
from the incautious and too lona^-con tinned exhibition of the drus^ in 
such cases. 

AYhen we have satisfied ourselves that abortion is inevitable, we 
must proceed to employ treatment that favors the expulsion of the 
ovum. 

If the OS be sufficiently dilated and the pains strong, we may find the 
ovum separated and protruding from the os. We may then be able to 
detach it by the finger. For this purpose the uterus is depressed from 
without by the left hand, while an endeavor is made to scoop out the 
ovum with the examining finger. If it be out of reach, and yet appear 
detached, chloroform should be administered, the whole hand intiwluced 
into the vagina and the finger into the uterine cavity. The complete 
detachment of the ovum can in this way be far more readily and safely 
effected than by using any of the many ovum-forceps which have been 
invented for the purpose. 

If the ovum be not sufficiently separated or the os be undilated, 
means must be taken to control the hemorrhage until the former can be 
removed or expelled. It is here that plugging of the vagina finds its 
most useful application. This may be done in various ways. That most 
usually employed is filling the vagina with a tolerably large sponge, in 
the interstices of which the blood coagulates. A better plan is to soak 
a number of pledgets of cotton-wool in carbolized water and tie a string 
round each. The vagina can be completely and effectively packed with 



ABORTION AND PREMATURE LABOR. 2o7 

these; and this is best done through a speculum, or, better still, ^vith 
the aid of a duck-bill specuhira, the patient being placed on her left 
side. Each pledget should be covered with glycerin, which completely 
prevents the offensive odor which otherwise always arises. The pledgets 
can be removed by traction on the strings, but if these are not used 
much pain is caused in getting them out of the vagina. The plug 
should never be left in for more than six or eight hours, after which a 
fresh one may be inserted if necessary. Two or three full doses of the 
liquid extract of ergot, of .5ss to 3j each, or a subcutaneous injection of 
ergotine, may be given while the plug is in position. The plug itself is 
a strong excitant of uterine action, and the two combined often effect 
complete detachment, so that on the removal of the tampon the ovum 
may be found lying loose in the os uteri. If the os be undilated 
and the ovum entirely out of reach, the former may be opened by 
means of sponge or laminaria tents. I think a well-prepared sponge 
tent the most effectual, and it can be maintained in situ by a vagi- 
nal plug below it. It also acts as a most efficient plug, effectually 
controlling all hemorrhage. In a few hours it opens up the os suf- 
ficiently to admit the finger. 

The most troublesome cases are those in which the foetus is first 
expelled and the placenta and membranes remain in utero. As long 
as this is the case the patient can never be considered safe from the 
occurrence of septicaemia. Dr. Priestley has strongly insisted on the 
importance of removing the secundines as soon as possible. There 
can be no doubt that this should be done whenever it is feasible. 
Cases, however, are frequently met with in which any forcible attempt 
at removal would be likely to prove very hurtful, and in which it 
is better practice to control hemorrhage by the plug or sponge tent; 
and wait until the placenta is detached, Avhich it will generally be 
in a day or two at most. Under such circumstances fetor and decom- 
position of the secundines may be prevented by intra-uterine injections 
of diluted Condy's fluid. Provided the os be sufficiently patulous 
to prevent the collection of the fluid in the uterine cavity, and not 
more than a drachm or two of the fluid injected at a time, so as 
simply to wash away and disinfect decomposing detritus, they can be 
used with perfect safety. Sometimes cases are met with in which 
the OS has entirely closed, and in which we can only suspect the 
retention of the placenta by the history of the case, the continuance 
of hemorrhage, or the presence of a fetid discharge. Should we see 
reason to suspect this, the os must be dilated with sponge or lami- 
naria tents, and the uterine cavity thoroughly explored under chloro- 
form. This condition of things is far from uncommon in women 
who have not had medical assistance from the first, and it otton 
gives rise to very troublesome and anxious symptoms. It has been 
said that placentic thus retained have been completely absorbed, and 
cases of the kind have been related by Xaegele and Osiander. The 
spontaneous absorption, however, of so highly organized a boilv as 
the })la('enta. would be a phenomenon of the most rouiarkable elia- 
racter ; and it seems more natural to suppose that in most cases oC 
the kind the placenta has been cast off without the knowknlge ot^ 
17 



258 PEEGyANCY. 

the patient. Sometimes the placenta never becomes entirely detached, 
and, retaining organic connection with the uterine walls, forms what 
has been called a " placental polypus.'^ This may produce secondary 
hemorrhage in the same way as an ordinary fibroid polypus. Barnes 
recommends the removal of these masses by means of a wire ecra- 
seur. Before their detection the os uteri must be opened up. 

Retention in iitero of a Blighted Ovum. — The cases previously 
alluded to, in which an ovum has perished in early pregnancy and 
is retained in utero, are often puzzling and may give rise to serious 
moral and medico-legal questions. The blighted ovum may be retained 
for many months, the outside limit, according to McClintock,^ by 
whom the subject has been ably discussed, being nine months. The 
appearance of the ovum when thrown oif will give no reliable clue 
to the length of time which has elapsed since it perished. The symp- 
toms are often very obscure. Generally there have been the usual 
indications of pregnancy, which, Avith or without signs of impending 
miscarriage, disappear or are modified, and then follows a period of 
ill-health, with pelvic uneasiness and irregular metrorrhagia, which 
may be mistaken for menstruation. Occasionally, but by no means 
necessarily, there is a fetid discharge, and this probably exists only 
when the membranes have broken and air has access to the ovum. 
In some cases obscure septicsemic symptoms have been observed. Such 
symptoms are obviously too indefinite to lead to an accurate diagno- 
sis. In the course of time the ovum is generally thrown oif, with 
more or less hemorrhage. If the nature of the case is detected, 
ergot may be given to promote the expulsion of the uterine contents, 
and it may even be advisable to dilate the cervix with sponge or 
laminaria tents and remove them artificially. 

Subsequent Management of Abortion. — The frequency with 
which abortion leads to chronic uterine disease should lead us to attach 
much more importance to the subsequent management of the patient 
than has been customary. The usual practice is to confine the patient 
to bed for two or three days only, and then to allow her to resume 
her ordinary avocations, on the supposition that a miscarriage requires 
less subsequent care than a confinement. The contrary of this is, 
however, most probably the case, for the uterus has been emptied 
when it is unprepared for involution, and that process is often very 
imperfectly performed. We should therefore insist on at least as much 
attention being paid to rest as after labor at term. 

^ Sydenham Society's edition of Smelli^s Midwifery, vol. i. p. 169. 



PART III 

LABOR. 



CHAPTER I. 

THE PHENOMENA OF LABOE. 

Delivery at Term. — In considering delivery at term wc have to 
discuss two distinct classes of events. 

One of these is the series of vital actions brought into play in order 
to effect the expulsion of the child ; and the other consists of the move- 
ments imparted to the child, the body to be expelled ; in other words, 
the mechanism of delivery. 

Causes of Labor. — Before proceeding to the consideration of these 
important topics a few words may be said as to the determining causes 
of labor. This subject has been from the earliest times a qucestio ve.v- 
ata among physiologists, and many and various are the theories which 
have been broached to explain the curious fact that labor sj)ontaueously 
commences, if not at a fixed epoch, at any rate approximately so. It 
must be- admitted that even yet there is no explanation which can 
be implicitly accepted. 

The explanations which have been giveu may be divided into two 
classes : those which attribute the advent of labor to the fcetus, and 
those which refer it to some change connected with the maternal 
generative organs. 

The former is the opinion which was held by the older accoucheurs, 
who assigned to the fcietus some active influence in eiibcting its own 
expulsion. It need hardly be said that such fanciful views have uo 
kind of physiological basis. Others have supposed that there might 
be some change in the placental circulation or in the vascular sys- 
tem of the foetus which might solve the mystery. 

The majority of obstetricians, however, refer the advent of labor to 
purely materual causes. Among the more favorite theories is one which 
was originally started in this country [/. e. Knglnnd] by Dr. Power, and 
adopted and illustrated by Depaul, Dubois, and other writers. It is 
based on the assumption that there is a sphincter action of the fibres 
of the cervix, analogous to that of the sphincters of the bladder and 
rectum, and that when the cervix is taken up into the general uterine 
cavity as ])regnancy advances, the ovum presses upon it, irritates its 
nerves, and so sets up reflex action, which ends in the establishment of 



260 LABOR. 

uterine contraction. This theory was founded on erroneous conceptions 
of the changes that occurred in the neck of the uterus ; and, as it is 
certain that obliteration of the cervix does not really take place in the 
manner that Power believed when his theory was broached, it is obvious 
that its supposed result cannot follow. A modification of this theory is 
that held by Stoltz and Bandl. According to this view, w^hen the cer- 
vix softens during the last two Aveeks of pregnancy the painless uterine 
contractions of gestation act upon the os internum, and open it suffi- 
ciently to admit of the ovum pressing on the lower segment of the 
uterus, and so inducing labor. 

Extreme distension of the uterus has been held to be the determining 
cause of labor — a view lately revived by Dr. King of Washington/ 
who believes that contractions are induced because the uterus ceases to 
augment in capacity, while its contents still continue to increase. This 
hypothesis is sufficiently disproved by a number of clinical facts which 
show that the uterus may be subject to excessive and even rapid disten- 
sion — as in cases of hydramnios, multiple pregnancy, and hydatidiform 
degeneration of the ovum — without the supervention of uterine contrac- 
tions. 

Another inciter of uterine action has been supposed to be the separa- 
tion of the ovum from its connections to the uterine parietes, in conse- 
quence of fatty degeneration of the decidua occurring at the end of 
pregnancy. The supposed result of this change, which undoubtedly 
occurs, is that the ovum becomes so detached from its organic adhesions 
as to be somewhat in the position of a foreign body, and thus incites the 
nerves so largely distributed over the interior of the uterus. This 
theory, which has been widely accepted, was originally started by Sir 
James Y. Simpson, who pointed out that some of the most efficient 
means of inducing labor (such, for example, as the insertion of a gum- 
elastic catheter between the ovum and the uterine walls) probably act in 
the same way — viz. by effecting separation of the membranes and 
detachment of the ovum. 

Barnes instances, in opposition to this idea, the fact that ineffectual 
attempts at labor come on at the natural term of gestation in cases of 
extra-uterine pregnancy, when the foetus is altogether independent of 
the uterus, and therefore, he argues, the cause cannot be situated in the 
uterus itself. A fair answer to this argument would be that although, 
in such cases, the womb does not contain the ovum, it does contain a 
decidua, the degeneration and separation of which might suffice to in- 
duce the abortive and partial attempts at labor then witnessed. 

Leopold^ suggests that the advent of labor may be connected with 
other changes in the decidua which occur in advanced pregnancy. He 
points out that then giant-cells, containing many nuclei, appear in the 
serotina which penetrate the uterine sinuses, and cause the formation in 
them of thrombi. The obstruction in the calibre of a number of these 
vessels leads to a stasis of the maternal blood returning from the pla- 
centa, and to an increase of carbonic acid in it, which may excite the 
motor centre for uterine contraction. 

^American Journal of Obstetrics, 1870-71, vol. iii. p. 561. 

'^"Studien iiber die Schleimhaut," etc., Arch. f. Gyn., 1877, Bd. xi. S. 443. 



THE PHENOMENA OF LABOR. 'A(j\ 

Objections to these Theories. — A serious objection to all tliese 
theories — which are based on the assumption that some local irrita- 
tion brings on contraction — is the fact which has not been generally 
appreciated, that uterine contractions are always present during preg- 
nancy as a normal occurrence, and that they may be, and often are, 
readily intensified at any time so as to result in ])remature delivery. 

It is indeed most likely that at or about the full term the nervous 
supply of the uterus is so highly developed, and in so advanced a state 
of irritability, that it more readily responds to stimuli than at other 
times. If by separation of the decidua or in some other way stimula- 
tion of the excitor nerves is then effected, more frequent and forcible 
contractions than usual may result, and, as they become stronger and 
more regular, terminate in labor. But, allowing this, it still remains 
quite unexplained why this should occur with such regularity at a def- 
inite time. 

Tyler Smith tried, indeed, to prove that labor came on naturally 
at what would have been a menstrual epoch, the congestion attending 
the menstrual nisus acting as the exciter of uterine contraction. He 
therefore refers the onset of labor to ovarian, rather than to uterine, 
causes. Although this view is upheld with all its author's great talent, 
there are several objections to it difficult to overcome. Thus, it assumes 
that the periodic changes in the ovary continue during pregnancy, of 
which there is no proof. Indeed, there is good reason to believe that 
ovulation is suspended during gestation, and with it, of course, the 
menstrual nisus. Besides, as has been well objected by Cazeaux, 
even if this theory were admitted, it would still leave the mystery 
unsolved, for it would not explain why the menstrual nisus should 
act in this way at the tenth menstrual epoch rather than at the 
ninth or eleventh. 

In spite, then, of many theories at our disposal, it is to be feared 
that we must admit ourselves to be still in entire ignorance of the reason 
why labor should come on at a fixed epoch. 

Mode in which the Expulsion of the Child is Effected. — The 
expulsion of the child is effected by the contractions of the muscular 
fibres of the uterus, aided by 'those of some of the abdominal muscles. 
These efforts are in the main entirely independent of volition. So far 
as regards the uterine contractions, this is absolutely true, for the mother 
has no power of originating, lessening, or increasing the action of the 
uterus. As regards the abdominal muscles, however, the mother is 
certainly able to bring them into action, and to increase their power bv 
voluntary efforts; but, as labor advances and the head passes into the 
vagina and irritates the nerves supplying it, the abdominal nuiscles are 
often stimukited to contract, through the inffuence of ivtlex action, inde- 
pendently of volition on the part of the mother. 

There can be little doubt that the chief agent in the exjnilsion o( the 
child is the contraction of the uterus itself This opinion is almost 
unanimously held by accoucheurs, and the inHuence oi' the abdominal 
nuiscles is believed to b^^ })ur(^ly accessory. Or. llaughton/ however, 

^ "On (ho jNIusoular lu>ives oiuplovoil in rarturiiion," etc., i)«6/m Quart. Jotuiu Med, 

Sc, 1870, vol. xlix. p. 4rn). 



262 LABOR. 

niaintaiDS a view which is directly contrary to this. From an exami- 
nation of the force of the uterine contractions, arrived at by measuring 
the amount of muscular fibre contained in the walls of the uterus, he 
arrives at tlie conclusion that the uterine contractions are chiefly in- 
fluential in rupturing the membranes and dilating the os uteri, bringing 
into action, if needful, a force equivalent to 54 pounds; but when this 
is eflected, and the second stage of labor has commenced, he thinks the 
remainder of the labor is mainly completed by the contractions of the 
abdominal muscles, to which he attributes enormous powers, equivalent, 
if needful, to a pressure of 523.65 pounds on the area of the pelvic 
canal. 

These views bear on a topic of primary consequence in the physi- 
ology of labor. They have been fully criticised by Duncan, who has 
devoted much experimental research to the study of the powers brought 
into action in the expulsion of the child. His conclusions are that, so 
far from the enormous force being employed that Haughton estimated, 
in the large majority of cases the eflective force brought to bear on the 
child by the combined action of both the uterine and abdominal mus- 
cles is less than 50 pounds — that is, less than the force which Haughton 
attributed to the uterus alone. In extremely severe labors, when the 
resistance is excessive, he thinks that extra power may be em])loyed; 
but he estimates the maximum as not above 80 pounds, including in 
this total the action of both the uterine and abdominal muscles. Joulin 
arrived at the conclusion that the uterine contractions were capable of 
resisting a maximum force of about one hundredweight. Both these 
estimates, it will be observed, are much under that of Haughton, which 
Duncan describes as representing ^' a strain to which the maternal 
machinery could not be subjected without instantaneous and utter 
destruction." 

There are many facts in the history of parturition which make it 
certain that the chief factor in the expulsion of the child is the uterus. 
Among these may be mentioned occasional cases in which the action of 
the abdominal muscles is materially lessened, if not annulled — as in 
profound anaesthesia and in some cases of paraplegia — in which, 
nevertheless, uterine contractions suffice to effect delivery. The most 
familiar example of its influence, however, and one that is a matter of 
every-day observation in practice, is when inertia of the uterus exists. 
In such cases no effort on the part of the mother, no amount of volun- 
tary action that she can bring to bear on the child, has any appreciable 
influence on the progress of the labor, which remains jn abeyance until 
the defective uterine action is re-established or until artificial aid is 
given. 

The contraction of the uterus, then, being the main agent in delivery, 
it is important for us to appreciate its mode of action and its effect on 
the ovum. 

Uterine Contractions at the Comniencenient of Labor. — AVe 
have seen that intermittent and generally painless uterine contractions 
exist during pregnancy. As the period for delivery approaches these 
become more frequent and intense, until labor actually commences, 
when they begin to be sufficiently developed to effect the opening up 



THE rilENOMENA OF LABOR. 2G3 

of the OS uteri with a view to the passage of the child. Tliey are now 
accompanied by pain, which increases as labor advances, and is so cha- 
racteristic that '^ pains ^' are universally used as a descriptive term for 
the contractions themselves. It does not necessarily follow that uterine 
contractions are painless unless they commence to effect dilatation of 
the OS uteri. On the contrary, during the last days or even weeks of 
pregnancy women constantly have irregular contractions, accompanied 
by severe suffering, which, however, pass off without producing any 
marked effect on the cervix. When labor has actually begun, if the 
hand is placed on the uterus when a pain commences, the contraction 
of its muscular tissue is very apparent, and the whole organ is observed 
to become tense and hard, the rigidity increasing until the pain has 
reached its acme, the uterine walls then relaxing, and remaining soft 
until the next pain comes on. At the commencement of labor these 
pains are few, separated from each other by a considerable interval, and 
of short duration. In a perfectly typical labor the interval between 
the pains becomes shorter and shorter, while at the same time the dura- 
tion of each pain is increased. At first they may occur only once in 
an hour or more, while eventually there may not be more than a 
few minutes' interval between them. 

If, when the pains are fairly established, a vaginal examination be 
made, the os uteri will be found to be thinned and dilated in propor- 
tion to the progress of the labor. During the contraction the bag of 
membranes will be felt to bulge, to become tense from the downward 
pressure of the liquor amnii within it, and to protrude through the os 
if it be sufficiently open. The membranes, with the contained licpior 
amnii, thus form a fluid wedge, which has a most important influence 
in dilating the os uteri (see Frontispiece). This does not, however, form 
the sole mechanism b}^ which the os uteri is dilated, for it is also acted 
upon by the contractions of the muscular fibres of the uterus, which 
tend to pull it open. It is probable that the muscular dilatation of the 
OS is effected chiefly by the longitudinal fibres, which as they shorten act 
upon the os uteri, the part where there is least resistance. 

Partly, then, by muscular contraction, partly by mechanical pressure, 
the cervical canal is dilated, and as it opens up it becomes thinner and 
thinner until it is entirely taken up into the uterine cavity. 

There is no longer any obstacle to the passage of the pi'csenting part 
of the child into the cavity of the pelvis, and the force of the pains 
now generally eflects the rupture of the membranes and the escape of 
the liquor amnii. There is often observed at this time a temporarv 
relaxation in the frequency of the pains, which had been steadily 
increasing; but they soon recouunence with increased vigtM*. If \\w 
abdomen be now examined, it will be observed to be nuich diminishinl 
in size, })artly in consequence of the escape of the liquor amnii, partly 
from the descent of the la^tusinto the pelvic cavity. 

The character of the pains soon changes. Thev become stroiiiier, 
longer in duration, separated by a shorter interval, and accompanied by 
a distinct forcing ctfort, being generally described as " the bearing-ilow n " 
pains. Now is the time at which the accessory nuiscles ot' part urii ion 
come into operation. The patient brings them into })lay in tlie manner 



264 LABOR. 

which will be subsequeDtly described, and the combined action of the 
uterine and abdominal muscles continues until the expulsion of the 
child is effected. 

The precise mode of uterine contraction is still somewhat a matter 
of dispute. It is generally described as commencing in the cervix, 
passing gradually upward by peristaltic action, the wave then return- 
ing downward toward the os uteri. This view was maintained by 
Wigand, and has been indorsed by Rigby, Tyler Smith, and many 
other writers. In support of it they instance the fact that on the acces- 
sion of a pain the presenting part first recedes, the bag of membranes 
then becomes tense and protrudes through the os, and it is not until 
some time that the presenting part of the child itself is pushed down. 
It is very doubtful if this view is correct ; and a careful examination 
of the course of the pains would rather lead to the belief that the con- 
tractions commence at the fundus, where the muscular tissue is most 
largely developed, and gradually proceed downward to the cervix. ; the 
waves of contraction being, however, so rapid that the whole organ 
seems to harden en masse. The apparent recession of the presenting 
part and the bulging of the bag of membranes are certainly no proof 
that the contractions begin at the cervix ; for the commencing contrac- 
tion would necessarily push down the fluid in front of the head, and 
cause the membranes to bulge and the os to become tense, before its force 
was brought to bear on the foetus itself. Indeed, did the contraction 
commence at the lower part of the uterus, we should expect the opposite 
of what takes place to occur, and the waters to be pushed upward and 
away from the cervix. The fundal origin of the contraction is further 
illustrated by what is observed wdien the hand of the accoucheur is 
placed in the uterine cavity, as often happens in certain cases of hemor- 
rhage or turning; for if a pain then comes on it Avill be felt to start at 
the fundus, and gradually compress the hand from above downward. 

Value of the Intermittent Character of the Pains. — The inter- 
mittent character of the contractions is of great practical importance. 
Were they continuous, not only would the muscular powers of the 
patient be rapidly exhausted, but by the obliteration of the vessels pro- 
duced by the muscular contraction the circulation through the placenta 
would be interfered with and the life of the child imperilled. Hence 
one of the chief dangers of protracted labor, especially after the -escape 
of the liquor amnii, is that the uterine fibres may enter into a state of 
tonic rigidity — a condition that cannot be long continued without serious 
risks both to the mother and child. 

The fact that the uterine contractions are altogether involuntary 
proves them to be excited — as indeed we would a priori infer from our 
knowledge of the anatomical arrangement of the nerves of the uterus — 
solely by the sympathetic system. Still, it is a fact of every-day obser- 
vation that they can be largely influenced by emotions. Various stimuli 
applied to the spinal system of nerves (as, for exam])le, when the mam- 
mae are irritated) have also a marked effect in inducing uterine contrac- 
tion. The precise mode in which such influence is conveyed to the 
uterus, in spite of the various experiments which have been made for 
tlie purpose of determining how far labor is alfected by destruction of 



THE PHENOMENA OF LABOR. 265 

the spinal cord, is still a matter of doul>t. After the foetus has passed 
through the cervix, the spinal nerves distributed to the vagina and 
perineum are excited by the pressure of the presenting part, an^l 
through them the accessory powers of parturition are chiefly brought 
into play. The contraction of the muscles of the vagina itself is sup- 
posed to liave some influence in favoring the expulsion of the fa*tus 
after the birth of part of the body, and also in promoting the expulsion 
of the placenta. In the lower animals the vagina has a very marked 
contractile property, and is, in some of them, the main agent by which 
the young are expelled. In the human subject this influence is certainly 
of very secondary importance. 

Character and Source of Pains during- Labor. — The amount of 
suffering experienced during labor varies much in different cases, and is 
in direct proportion to the nervous susceptibility of the patient. There 
are some women who go through labor with little or no pain at all. 
This is proved by the cases (of which there are numerous authentic 
instances recorded) in which labor has commenced during sleep, and 
the child has been actually born without the mother awaking. I am 
acquainted with a lady who has had a large family who assures me that, 
though labor is accompanied by a sense of pressure and discomfort, she 
experiences nothing which can be called actual pain. Such a happy 
state of affairs is, however, extremely exceptional, and in the vast 
majority of cases parturition is accompanied by intense suffering during 
its w^hole course, in some cases amounting to anguish which has proba- 
bly no parallel under any other condition. 

The precise cause of the pain has been much discussed, and is no 
doubt complex. 

In the early stage of labor, and before the dilatation of the os, it is 
chiefly seated in the back, from whence it shoots round the loins and 
down the thighs. It is then probably produced partly by pressure on 
the nerve-filaments caused by contraction of the muscular fibres to 
which they are distributed, and partly by stretching and dilatation of 
the muscular tissue of the cervix. M. Beau believes that in this stage 
the pain is not produced, strictly speaking, in the uterus itself, but is 
rather a neuralgia of the lumbo-abdominal nerves. The pains at this 
time are generally described as ^^acute '' and ^^ grinding" — terms which 
sufficiently well express their nature. In highly nervous women these 
pains are often much less well borne than those of a later stage, and the 
suffering they undergo is indicated by their extreme restlessness and 
loud cries as each contraction su])ervenes. 

As the OS dilates and the labor advances into the exjudsive stage other 
sources of suffering are added. The presenting ptirt now passes into the 
vagina and presses on the vaginal nerves, as well as on the large ner- 
vous plexuses lying in the pelvis. As it descends lower it stretches the 
perineum and vulva, and jnvsses on the bladder and rectum. Hence 
cramps are })ro(luced in the nuiscles supplied by the nerve-])lexuses. as 
well as an intolerable sense o\^ tearing and stretching in the vulva and 
])(M-in(>nni, and oIUmi a distressing feeling of tenesnuis in the Innvels. 
J^v this time tlu> accessory muscles ol' pariuriti^^n are brought '\u\o action, 
and they, as well as thc^ uterim^ miiscl(\><, are thr(n\ n into I'reipient and 



266 LABOR. 

violent contractions, which, independently of the other causes mentioned, 
are sufficient of themselves to produce great pain, likened to that of 
colic, produced by involuntary and repeated contraction of the muscles 
of tlie intestines. 

Taking all these causes into consideration, there is no lack of sufficient 
explanation of the intolerable suffering which is so constant an accom- 
paniment of childbirth. * 

Effect of the Pains on the Mother and Foetus. — The effect of the 
pains on the mother's circulation is Avell marked. The rapidity of the 
pulse increases distinctly with each contraction, and as the pain passes 
off it again declines to its former state. A similar observation has been 
made with regard to the sounds of the foetal heart, especially after the 
expulsion of the liquor amnii. Hicks has pointed out that during a pain 
the muscular vibrations give rise to a sound which often resembles that 
of the foetal heart, and which completely disappears when the muscular 
tissue relaxes. The effect of the pain in intensifying the uterine souffle 
has been already mentioned. The strong muscular efforts would natu- 
rally lead us to expect a marked elevation of temperature during labor. 
Further observations on this point are required ; but Squire asserts that 
there is generally only a very slight increase in temperature during 
delivery, rapidly passing off as soon as labor is over. 

Division of Labor into Stages. — Such being the physiological 
facts in connection with labor-pains, we may now describe the ordinary 
progress of a natural labor — that is, one terminated by the natural pow- 
ers and with a head presenting. 

For facility of description obstetricians have long been in the habit 
of dividing the course of labor into stages, which correspond pretty accu- 
rately with the natural sequence of events. For this purpose w^e gen- 
erally talk of three stages: viz. (1) from the commencement of regular 
pains until the complete dilatation of the cervix {stage of effacement and 
dilatation) ; (2) from the complete dilatation of the cervix until the 
expulsion of the child {stage of expulsion) ; (3) the concluding stage, 
comprising the permanent contraction of the uterus and the separation 
and expulsion of the placenta {stage of the after-birth). To these we 
may conveniently add a preparatory stage, antecedent to the regular 
commencement of the labor. 

Preparatory Stage. — For a short time before delivery, varying 
from a few days to a week or two, certain premonitory symptoms gen- 
erally exist which indicate the approaching advent of labor. Sometimes 
they are well marked and cannot })e mistaken ; at others they are so 
slight as to escape observation. Amongst the most common is a sink- 
ing of the uterus into the pelvic cavity, resulting from the relaxation of 
the soft parts preceding delivery. The result is that the upper edge of 
the uterine tumor is less high than before, and in consequence the pres- 
sure on the respiratory organs is diminished, and the woman often feels 
lighter and altogether less unwieldy than in the previous weeks. If a 
vaginal examination be made at this time, the lower segment of the 
uterus will be found to have sunk lower into the pelvic cavity ; and the 
consequence of this is that, while the respiration is less embarrassed and 
the patient feels less bulky, other accompaniments of pregnancy, such 



THE PHENOMENA OF LABOR. 267 

as hemorrhoids, irritability of the bladder and bowels, and rjedenia of 
the limbs, become aggravated. The increased pressure on the bowels 
often induces a sort of temporary diarrhoea, which is so far advantageous 
that it empties the bowels of feces which may have collected within 
them. As has already been pointed out, the contractions which have 
been going on at intervals during the latter months of pregnancy now 
get more and more marked, and they have the effect of producing a real 
shortening of the cervix, which is of great value preparatory to its dila- 
tation. More marked mucous discharge from the cavity of the cervix 
also generally occurs a short time before labor, and it is not unfrequently 
tinged with blood from the laceration of minute capillary vessels. This 
discharge, popularly known as the '' shotvs/^ is a pretty sure sign that 
labor is not far off. It may, however, be entirely absent, even until the 
birth of the child. When copious, it serves to lubricate the passages, 
and is generally coincident with rapid dilatation of the parts and a 
speedy labor. 

During this time (premonitory stage) painful uterine contractions are 
often present, which, however, have no effect in dilating the cervix. In 
some cases they are frequent and severe, and are very apt to be mistaken 
for the commencement of real labor. Such ^' false jjains/^ as they are 
termed, are often excited and kept up by local irritations, such as a 
loaded or disordered state of the intestinal canal ; and they frequently 
give rise to considerable distress and much inconvenience both to the 
patient and practitioner. They are, it should be remembered, only the 
normal contractions of the uterus, intensified and accompanied with 
pain. 

First Stag-e, or Dilatation. — As labor actually commences the 
uterine contractions become stronger, and the fact that they are " true " 
pains can be ascertained by their effect on the cervix. If a vaginal 
examination be made during one of these, the membranes will be felt to 
become tense and bulging during the pain, and the os uteri will be found 
partially dilated and thinned at its edges. As labor advances this effect 
on the OS becomes more and more marked. At first the dilatation is very 
slight, perhaps not more than enough to admit the tip of the examining 
finger, and both the upper and lower orifices of the cervix can be made 
out. As the pains get stronger and more frequent, dilatation proceeds 
in the way already described and the cervix gets more thin and tense, 
until we can feel a thin circular ring (which is lax between the pains, 
but becomes rigid and tense during the contraction when the bag of 
waters bulges through It) without any distinction between the up]XM" and 
lower orifices. During this time the patient, although she m;iy be sut- 
ferlng acutely, is generally able to sit up and walk al)ont. The amount 
of pain experienced varies much according to the character ot' the 
patient. In emotional Avomen of highly- developed nervous susei>ptlblli- 
tles It is generally very great. They are restless, irritable, ami despond- 
ing, and when the pain comers on cry out loudly. The character ot' the 
cry is peculiar and well marked dm-ing the first stage, and has constantly 
been described by obsU^tric wrlt(>rs as charat'terlstu\ It is acute and 
high, and is certainly verv dltferent ivom the di>ep groans ot'the second 
stage, when the breath Is InvoliuUarlly iviained to assist the paniirient 



268 LABOR. 

effort. When dilatation is nearly completed various reflex nervous phe- 
nomena often show themselves. One of these is nausea and vomiting ; 
another is uncontrollable shivering, Avhich is not accompanied by a 
sense of coldness, the patient being often hot and perspiring. Both 
these symptoms indicate that the propulsive stage will shortly com- 
mence ; and they may be regarded as favorable rather than otherwise, 
although they are apt to alarm the patient and her friends. By this 
time the os is fully dilated, the membranes generally rupture sponta- 
neously, and a considerable portion of the liquor amnii flows aw-ay. 
The head, if presenting, often acts as a sort of ball- valve, and, falling 
down on the aperture of the cervix, prevents the complete evacuation 
of the liquor amnii, which escapes by degrees during the rest of the 
labor, or may be retained in considerable quantity until the birth of the 
child. 

It not unfrequently happens, if the membranes are somewhat tougher 
than usual and the pains frequent and strong, that the foetus is pushed 
tjirough the pelvis, and even expelled surrounded by the membranes. 
AYhen this occurs the child is said to be born with a " caul,^^ and this 
event would doubtless happen more frequently than it does w^ere it not 
the custom of the accouclieur to rupture the membranes artificially as 
soon as the os is completely opened up, after which time their integrity 
is no longer of any value. 

The OS is now entirely retracted over the presenting part, and is no 
longer to be felt, the vagina and the uterine cavity forming a single 
canal. I^ow the mucous discharge is generally abundant, so that the 
examining finger brings away long strings of glairy, transparent mucus 
tinged with blood. The pains, after a short interval of rest, become 
entirely altered in character. The uterus contracts tightly round the 
foetus, the presenting part descends into the pelvis, and the true propul- 
sive pains commence. The accessory muscles of parturition noW' come 
into play. With each pain the patient takes a deep inspiration, and 
thus fills the chest so as to give a point (Tappui to the abdominal 
muscles. For the same reason she involuntarily seizes hold of some 
point of support, as the liand of a bystander or a towel tied to the bed, 
and at the same time pushes with her feet against the end of the bed, 
and so is able to bear down to advantage. The cries are no longer 
sharp and loud, but consist of a series of deep suppressed groans, which 
correspond to a succession of short expirations made during the strain- 
ing effort. In this way the abdominal muscles contract forcibly on the 
uterus, which they further stimulate to action by pressing upon it. It 
is to be observed that these straining efforts are, to a considerable extent, 
under the control of the patient. By encouraging her to hold her breath 
and bear down they can be intensified, while if we wish to lessen them 
we can advise her to call out, and when she does so the abdominal 
muscles have no longer a fixed point of action. Although the ])atient 
may thus lessen the effect of these accessory muscles, it is entirely out 
of her power to stop their action altogether. As labor advances the 
head descends lower and lower, receding somewhat in the intervals 
between the pains, until eventually it comes down on the perineum, 
which it soon distends. 



THE PHENOMENA OF LABOR. 269 

The pains now get stronger and more frequent, often witli scareely a 
perceptible interval between them, until the perineum gets stretched by 
the advancing head. In the interval between the pains the elasticity 
of the perineal structures pushes the head upward so as to diminish the 
tension to which the perineum is subjected, the next pain again putting 
it on the stretch and protruding the head a little farther than before. 
By this alternate advance and recession the gradual yielding of the 
structures is favored and risk of laceration greatly diminished. During 
this time the pressure of the head mechanically empties the bowel of 
its contents. During the last pains, when the perineum is stretched to 
the utmost, the anal aperture is dilated, sometimes to the size of a [sil- 
ver dollar] ; and in this way the perineum is relaxed, just as the dis- 
tension, and consequent risk of laceration, are at their maximum. The 
apex of the head now protrudes more and more through the vulva, 
surrounded by the orifice of the vagina, and eventually it glides over 
the perineum and is expelled. The intensity of the suffering at this 
moment generally causes the patient to call out loudly. The force of 
the abdominal muscles is thus lessened at the last moment, and this, in 
combination with the relaxation of the sphincter ani, forms an admira- 
ble contrivance for lessening the risk of perineal injury. The rest of 
the body is generally expelled immediately by a single pain, and with 
it are discharged the remains of the liquor amnii and some blood-clots 
from separation of the placenta; and so the second stage of labor 
terminates. 

The Third Stage. — The third stage commences after the expulsion 
of the child. It is of paramount importance to the safety of the 
mother that it should be conducted in a natural and efficient manner ; 
for it is now that the uterine sinuses are closed, and the frail barrier by 
which nature effects this may be very readily interfered with, and seri- 
ous and even fatal loss of blood ensue. Unfortunately, it is too often 
the case that the practitioner's entire attention is fixed on the expulsion 
of the child, so that the natural history of the rest of delivery is very 
generally imperfectly studied and understood. 

As soon as the child is expelled the uterine fibres contract in all 
directions, and the hand, following the uterus down, will find that it 
forms a firm rounded mass lying in the lower part of the abdominal 
cavity. By retraction of its internal surface the placental attachments, 
which probably remain undisturbed until the expulsion of the child, 
are generally separated, and the after-birth remains in the cavity of the 
uterus as a foreign body. 

The escape of blood from the open mouths of the uterine sinuses is 
now^ prevented in two ways: viz. (1) by the contractions of the uterine 
walls; and tlie more firm, persistent, and tonic this is the more certain 
is the immunity from hemorrhage; (2) by the formation of c\)agula in 
the mouths of the vessels. Any undue haste in promoting the expul- 
sion of the placenta tends to ])revent the latter of these two haMuosiatic 
safeguards, and is apt to be followed by loss of blood. After a certain 
time, averaging from a quarter to half an hour, the uterus will bo telt 
to harden, and, if the case be solely left to nature, what has boon aptly 
called a miniature labor occurs. Pains (>onie on, and the placenta is 



270 



LABOR 



Fig. 98. 



spontaneously expelled from the uterus, either into the canal of the 
vagina or even externally. In most obstetric works it is stated that the 
after-birth may be separated either from its centre or edge, and that it 
is very generally expelled through the os in an inverted form, ^^ ith its 
foetal surface downward, and folded transversely on itself. That this is 
the mode in which the placenta is often expelled when traction on the 
cord is practised is a matter of certainty. It then passes through the os 
very much in the shape of an inverted umbrella. It is certain, how- 
ever, that tliis is not the natural mechanism of its delivery. The sub- 
ject has been well studied by Berry Hart," who has shown that during 
the contractions of the third stage of labor the placenta is "thrown into 
heights and hollows," and, if the case be left entirely to nature, it 
descends with its edge or a point near its edge first, 
its uterine and detached surface gliding along the 
inner surface of the uterus, the foldings of its 
structure being parallel to the long diameter of the 
uterine cavity (Fig. 98). In this way it is expelled 
into the vagina, and during the process little or no 
hemorrhage occurs. When the placenta is drawn 
out in the way too generally practised, it obstructs 
the aperture of the os, and, acting like the piston 
of a pump, tends to promote hemorrhage. The 
corollaries as to treatment drawn from these facts 
will be subsequently considered. I am anxious, 
however, here to direct attention to nature's mech- 
anism, because I believe there is no part of labor 
about the management of which erroneous views 
are more prevalent than that of this stage, and 
none in which they are more apt to lead to serious 
Mode in which the Pia- couscqueuces; and unless the mode in which Nature 
peii?d.^^(/fterDuncS effects the cxpulsiou of the placenta and prevents 
hemorrhage is thoroughly understood, we shall cer- 
tainly fail in assisting her in a proper manner. In the large propor- 
tion of cases, when left entirely to themselves, the placenta would be 
retained, if not in the uterus, at any rate in the vagina, for a consider- 
able time — possibly for several hours; and such delay would very 
unnecessarily tire the patience of the practitioner and be prejudicial 
to the patient. It is, therefore, our duty in the majority of cases to 
promote the expulsion of the after-birth ; and when this is properly 
and scientifically done w^e increase rather than diminish the patient's 
safety and comfort. But in order to do this we must assist Nature, and 
not act in opposition to her method, as is so often the case. 

After-Pains. — AVhen once the placenta is expelled the nterus con- 
tracts still more firmly, and in a typical case is felt just within the 
pelvic brim, hard and firm, and about the size of a cricket-ball. Gen- 
erally for several hours, or even for one or two days, it occasionally 
relaxes and contracts, and these contractions give rise to the '' after- 
pains^^ from which women often suffer much. The object of these 
pains is no doubt to expel any coagula that may remain in the uterus, 
^ *' Sectional Anatomy of Labor," Edin. Med. Journ., November, 1887. 




THE PHENOMENA OF LABOR. 'IIX 

and therefore, however unpleasant they may be to the patient, they 
must be considered, unless very excessive, to be salutary rather than 
otherwise. 

Duration of Labor. — The length of labor varies extremely in differ- 
ent cases, and it is quite impossible to lay down any definite rules with 
regard to it. Subject to excjeptions, labor is longer in primiparse than 
in multiparse, on account of the greater resistance of the soft parts in 
the former, especially of the structures about the vagina and vulva. 
It is also generally stated that the difficulty of labor increases with the 
age of the patient, and that in elderly primiparse it is likely to be 
unusually tedious, from rigidity of the soft parts. It is very doubtful 
if this opinion has any real basis, and in such cases the practitioner 
often finds himself agreeably disappointed in the result. Mr. Roper,^ 
indeed, argues that the wasting of the tissues which occurs after forty 
years of age diminishes their resistance, and that first labors after that 
age are easier, as a rule, than in early life. The habits and mode of 
life of patients have no doubt a considerable influence on the duration 
of labor, but we are not in possession of any very reliable facts with 
regard to this subject. It is reasonable to suppose that the tissues of 
large, muscular, strongly-developed women will offer more resistance 
than those of slighter build. On the other hand, women of tiie latter 
class, especially in the up]3er ranks of life, more often develop nervous 
susceptibilities, which may be expected to influence the length of their 
labors. The average duration of labor, calculated from a large number 
of cases, is from eight to ten hours ; even in primiparse, ho\Yever, it is 
constantly terminated in one or two hours from its commencement, and 
may be extended to twenty-four hours without any symptoms of urgency 
arising. In multiparifi it is frequently over in even a shorter time. 
Indications calling for interference may arise at any time during the 
progress of labor, independently of its length. The proportion between 
the length of the first and second stages also varies considerably. The 
first stage is generally the longest, and it is stated by Cazeaux to be 
normally about twice the length of the second. This is probably under 
the mark, and I believe Joulin to be nearer the truth in stating that 
the first stage should be to the second as four or five to one, rather than 
as two to one. Often when the first stage has been very prolonged the 
second is terminated rapidly. 

The practitioner is constantly asked as to the probable length of labor, 
and the uncertainty of this should always lead him to give a most 
guarded opinion. Even when labor is progressing a})parently in the 
most satisfactory manner the pains frequently die away, and delivery 
may be delayed for many Ikhu'S. In the first stage a cervix that is 
apparently rigid and unyielding may rapidly and unexpectedly dilate, 
and delivery soon follow. In either case, if the practitioner has com- 
mitted himself to a positive opinion he is apt to incur blame, and it is 
far better always to be extremely cautious in our predictions on liiis 
point. 

Period of the Day at -which Labor Occurs A somew hat larger 

}>ro])()rtion of deliveries occur in the early hours of the morning than at 

' O^t. Tnvis., 1S8(). vol. vii. p. o\. 



272 LABOR. 

other times. Thus, West ^ found that out of 2019 deliveries, 780 took 
place from 11 p. m. to 7 A. M., 662 from 7 A. j\[. to 3 P. M., and 577 
from 3 p. M. to 11 p. m. 



CHAPTER II. 
MECHANISM OF DELIVEEY IN HEAD PKESENTATION. 

Importance of the Subject. — It is quite impossible to over-estimate 
the importance. of thoroughly undefitanding^he meclianism~of the pas- 
s^e of tlie foetus through the pelvis. This dominates the Avhole scien- 
tific practice of midwifery, and the practitioner cannot acquire more than 
a merely empirical knowledge, such as may be possessed by any unedu- 
cated midwife, or conduct the more difficult cases requiring operative 
interference with safety to the patient or satisfaction to himself, unless 
he thoroughly masters the subject. 

In treating of the physiological phenomena of labor it was assumed 
that we had to do with an ordinary case of head presentation, the descrip- 
tion being applicable, with slight variations, to presentations of other 
parts of the foetus. So in discussing the mechanical phenomena of 
delivery I shall describe more in detail the mechanism of head presenta- 
tions, reserving any account of the mechanism of other presenta- 
tions until they are separately studied. Head presentation is so much 
more frequent than that of any other part — amounting to 95 per cent, 
of all cases — that this mode of studying the subject is fully justified; 
and, when once the student has mastered the phenomena of delivery in 
head presentations he will have little difficulty in understanding the 
mechanism of labor when other parts of the foetus present, based, as it 
always is, on the same general plan. 

Mode of Recognizing the Position of the Head by its Sutures 
and Pontanelles. — In entering on this study we come to appreciate the 
importance of the sutures and fontanelles in enabling us to detect the 
position of the foetal head, and to watch its progress through the pelvis ; 
and unless the tadus eruditus by which these can be distinguished from 
each other has been acquired, the practitioner will be unable to satisfy 
himself of the exact progress of the labor. Nor is this always easy. 
Indeed, it requires considerable experience and practice before it is pos- 
sible to make out the position of the head with absolute certainty ; but 
this knowledge should always be aimed at, and the student will never 
regret the time and trouble he spends in acquiring it. 

At the commencement of labor the long diameter of the head lies in 
almost any diameter of the pelvic brim, except in the antero-posterior, 
where there is not space for it. In tho large majority of cases, how- 

^ Amer. Med. Journ., 1854. 



MECHANISM OF DELIVERY IN HEAD PRESENTATION. 273 

ever, it enters the pelvis in one or other of the oblique diameters, or in 
one between the oblique and transverse ; but until it has fairly passed 
through the brim it more frequently lies directly in the transverse diam- 
eter than has been generally supposed. Hence obstetricians are in the 
habit of describing the head as lying in four positions according to the 
parts of the pelvis to which the occiput points ; the first and third posi- 
tions being those in which the long diameter of the head occupies the 
right oblique diameter of the pelvis, the second and fourth those in 
which it lies in the left oblique. Many subdivisions of these positions 
have been made, which only complicate the subject and render it more 
difficult to understand. 

Four Positions Described. — The positions, then, of the foetal head 
after it has entered the brim, which it is of importance to be able to 
distinguish in practice, are — 

First {left occipito-anterioi' , occipito-lceva anterior, O.L.A.). — The occi- 
put points to the left foramen ovale, the sinciput to the right sacro-iliac 
synchondrosis, and the long diameter of the head lies in the right ob- 
lique diameter of the pelvis. 

Second {right occipito-anterior, occipito-dextra anterior, o.d.a.). — 
The occiput points to the right foramen ovale, the forehead to the left 
sacro-iliac synchondrosis, and the long diameter of the head lies in the 
left oblique diameter of the pelvis. 

Third {right occipito-posterior, occipito-dextra posterior, o.d.p.). — 
The occiput points to the right sacro-iliac synchondrosis, the forehead to 
the left foramen ovale, and the long diameter of the head lies in the 
right oblique diameter of the pelvis. This position is the reverse of the 
first. 

Fourth {left occipito-posterior, occipito-lceva posterior, o.l.p.). — The 
occiput points to the left sacro-iliac synchondrosis, the forehead to the 
right foramen ovale, and the long diameter of the head lies in the left 
oblique diameter of the pelvis. This position is the reverse of the 
second. 

The relative frequency of these positions has long been, and still is, 
a matter of discussion among obstetricians. According to Kaegele, to 
whose classical essay we owe the greater part of our knowledge of the 
subject, the head lies in the right oblique diameter in 99 per cent, of all 



Naegele 

Naegele, Jr. . . . 
Simpson and Barry 

Dubois 

Murphy 

Swayne 



First 


Second 


Position 


Position 


(O.L.A.) 


(O.D.A.) 


70.00 


_ 


64.64 





76.45 


.29 


70.83 


2.87 


63.23 


16.18 


86.36 


9.79 



Third 
Position 

(O.D.P.) 



29.00 
32.88 
22.68 
25.66 
16.18 
1.04 



Fourth ! ^TQt 
?ol^S^Classified 



.58 

.62 

4.42 

2.8 



1.00 
2.47 



cases. More recent researches have thrown some doubt on tho accuracy 
of these figures, and many modern obstetricians believe that the second 
(o.d.a.) position, which JNaegele believed only to bo observed as a 

IS 



274 LABOR. 

transitional stage in the natural progress of the third (o.d.p.) posi- 
tion, is much more common than he supposed. This question Avill be 
more fully discussed when we treat of the mechanism of occipito- 
posterior delivery, and in the mean time it may serve to show the 
discrepancy which exists in the opinions of modern writers if we 
furnish the preceding table of the relative frequency of the various 
positions/ copied from Leishman^s work. Here it will be seen that 
all obstetricians are agreed as to the immensely greater frequency of 
the first (o.L.A.) position — the only point at issue being the relative 
frequency of the second (o.d.a.) and third (o.d.p.). 

Various explanations have been given of the greater frequency with 
which the head lies in the right oblique diameter. By some it is 
referred to the natural tendency of the back of the foetus, as shown by 
the experimental researches of Honing and other writers, to be directed, 
in consequence of gravitation, forward and to the left side of the 
mother in the erect attitude, and backward and to her right side in 
the recumbent. The explanation given by Simpson was that the head 
lay in the right oblique diameter in consequence of the measurement of 
the left oblique being more or less lessened by the presence of the 
rectum. When the rectum is collapsed, indeed, the narrowing of 
the diameter is slight; but it is so often distended by fecal matter — 
sometimes, when constipation exists, to a very great extent — that it may 
really have a very important influence in determining the position of 
the foetal head. 

In describing the mechanism of delivery it will be well for us to con- 
centrate our attention on the first (o.l.a.) or most common position, 
dwelling subsequently more briefly on the diiferences between it and 
the less common ones. 

Description of the First Position. — In this position, when the head 
commences to descend the occiput lies in the brim pointing to the left 
ileo-pectineal eminence, the forehead is directed to the right sacro-iliac 
synchondrosis, and the sagittal suture runs obliquely across the pelvis in 
the right-oblique diameter. The back of the child is turned toward the 
left side of the mother's abdomen, the right shoulder to her right side, 
the left to her left side (Fig. 99). If a vaginal examination be now 
made (the patient lying in the ordinary obstetric position), and the os be 
sufficiently open, the finger will impinge upon the protuberance of the 
right parietal bone, which is described as the "presenting part" — a term 
which has received various definitions, the best of which is probably that 
adopted by Tyler Smith — viz. "that portion of the foetal head felt most 
prominently Avithin the circle of the os uteri, the vagina, and the os 
tincse in the successive stages of labor.'' If the tip of the examin- 
ing finger be passed slightly upward, it will feel the sagittal suture 
running obliquely across the pelvis, and if this be traced downward and 
to the left it will come upon the triangular posterior fontanelle, with the 
lambdoidal sutures diverging from it. If the finger could be passed 
sufficiently high in the opposite direction, upward and to the right, it 
would come upon the large anterior fontanelle; but at this time that is 
too high up to be within reach. The chin is slightly flexed upon the 

^ Leishman's System of Midwifery, p. 341. 



MECHANISM OF DELIVERY IN HEAD PRESENTATION. 275 

sternum, this flexion, as we shall presently see, being greatly increased 
as the head begins to descend. 

The head at the commencement of labor generally lies within the 

Fig. 99. 




Attitude of Child in First Position (o.l.a.). (After Hodge.) 

pelvic brim, especially in primiparse. In multiparas, owing to the 
relaxation of the abdominal parietes, the uterus is apt to fall some- 



FiG. 100. 




First Position (o.L.-'V.) : movement of tlexiou 



what forward, and the head eonsoquoutly is more entirely above the 
brim, but is pushed within it as .^oon as labor aetiially oouinionoes. 



276 LABOR 

Naegele — and his description has been adopted by most subsequent 
writers — describes the head at this period as lying obliquely in relation 
to the brim, the right parietal bone, on which the examining finger im- 
pinges, being supposed by him to be much lower than the left. The 
accuracy of this view^ has of late years been contested, and it is now 
pretty generally admitted that this obliquity does not exist, and that the 
head enters the brim of the pelvis with both parietal bones on the same 
level, and with its biparietal diameter parallel to the plane of the inlet 
(Fig. 100). Naegele's view was adopted partly because the finger always 
felt the right parietal protuberance lowest, and partly because it was at 
that point that the caput succedaneumj or swelling observed on the head 
after delivery, was always formed. Both arguments are, however, 
fallacious ; for the right parietal bone is the part which would naturally 
be felt lowest, on account of the oblique position of the pelvis to the 
trunk; while wdth regard to the caput succedaneum it has been conclu- 
sively proved by Duncan that it does not form on the point most 
exposed to pressure, as Naegele assumed, but on the part of the head 
where there is least pressure ; that is, the i3art lying over the axis of the 
vaginal canal. 

Division of Mechanical Movements into Stages. — In tracing the 
progress of the head from the position just described obstetricians have 
been in the habit of dividing the movements it undergoes into various 
stages, which are convenient for the purpose of facilitating description. 
It must be borne in mind that these are not evident and distinct stages, 
which can always be made out in practice, but that they run insensibly 
into one another, and often occur simultaneously, or nearly so, in rapid 
labor. They may be described as — 1. Flexion. 2. First movement of 
descent. 3. Levelling or adjusting movement. 4. Rotation. 5. Second 
movement of descent and extension. 6. External rotation. 

1. Flexion. — The first movement of the head consists of a rotation on 
its biparietal diameter, by which the chin of the child becomes bent on 
the sternum and the occiput descends lower than the forehead. By this 
there is a clear gain of at least half an inch, for the occipito-bregmatic 
diameter (3J inches) becomes substituted for the occipito-frontal 
(41 inches) (Fig. 100). 

The movement is most marked when the pelvis is narrow, and in 
some cases of pelvic deformity it takes place to an extreme degree, 
while in unusually large and roomy pelves it occurs to a very slight 
extent or not at all. The reason of this flexion is twofold. Solayres and 
the majority of obstetricians explain it by saying that the expulsive 
force is communicated to the head through the vertebral column, and, 
inasmuch as the head is articulated much nearer the occiput than the 
sinciput, the resistance being equal, the former must be pushed down. 
This is doubtless the correct explanation of the flexion after the mem- 
branes are ruptured, but before that happens the ovum is practically a 
bag of water, which is equally compressed at all points by the uterine 
contraction, and is pushed dowmward through the os en masse, the expul- 
sive force not being transmitted through the vertebral column at all. 
Under such circumstances flexion is probably effected in the following 
way : the head being articulated nearer the occiput than the forehead, 



MECHANISM OF DELIVERY IN HEAD PRESENTATION. 277 

and being equally pressed upon from below by the resisting structures, 
the pressure is more effectual on the forehead ; consequently, that is 
forced upward and the occiput descends. This explanation would also 
hold good after the rupture of the membranes, and probably both causes 
assist in effecting the movement. 

2 and 3. Descent and Levelling Movement — The movements oi descent 
and levelling may be described together. As soon as the head is lib- 
erated from the os uteri, it descends pretty rapidly through the pelvis 
until the occiput reaches a point nearly opposite the lower part of the 
foramen ovale (Fig. 101) and the sinciput is opposite the second bone 

Fig. 101. 




First Position (o.l.a.) : Occiput in the Cavity of the Pelvis. (After Hodge.) 

of the sacrum. A levelling movement now occurs : the anterior fonta- 
nelle comes to be more easily within reach, more on a level with the pos- 
terior, and the chin is no longer so much flexed on the sternum. This 
change is due to the fact that the anterior end of the ovoid experiences 
greater resistance than the posterior, and as soon as this resistance coun- 
terbalances and exceeds that applied to the latter the sinciput must 
descend. The right side of the head also descends more than the left 
from a similar cause, so that the head becomes, as it were, slightly 
flexed on the right shoulder. This obliquity of the head on its trans- 
verse diameter in the lower part of the pelvis has been denied by 
Kiineke/ who maintains that the head passes through the entire pelvis 
in the same position as it enters the brim — that is, with both parietal 
bones on a level — so that the point of intersection of the transverse and 
antero-posterior diameters of the pelvis would corresjiond with the sag- 
ittal suture. There is, however, good reason to believe that in the lower 
half of the pelvic cavity the head is not truly synclitic, as Kiiueke 
describes, but that the right parietal bone is on a somewhat lower level 
than the left. 

4. Rotation. — The movement of rotation is very inqiortant. By it 
the long diameter of the head is changed from the oblique diameter of 
the pelvic cavity to the antero-posterior diameter of the outlet (Fig. 102\ 
or to a diameter nearly corresponding to it, so that the long diameter of 
the head is brought into relation with the longest diameter of the pelvic 
outlet. This alteration almost always takes ]>laee, and may be readily 
observed by the aeeoucljeur who carefully watches the progress ot' hdnn*. 
Various explanations have been given of its causes. TluM>no most geu- 

^ /)/«' vicr Fadorcn dcr Gtburt, Horliu. ISill). 



278" LABOR. 



erally adopted is that it is due to the projection inward of the ischial 
spines, which narrow the transverse diameter of the pelvic outlet. As 
the pains force tlie occiput downward its rotation backward is prevented 
by the projection of tlie left ischial spine, while its rotation forward is 
favored by the smooth, bevelled surface of the ascendincr ramus of the 



Fig. 102. 




First Position (o.l.a.) : Occiput at Outlet of the Pelvis. (After Hodge.) 

ischium. Similarly, the ischial spine on the opposite side prevents the 
rotation forward of the forehead, which is guided backward to the 
cavity of the sacrum by the smooth surface of the sacro-ischiatic liga- 
ments. These arrangements, therefore, give a screw-like form to the 
interior of the pelvis ; and as the pains force the head downward, they 
are effectual in imparting to it the rotatory movement which is of such 
importance in adapting it to the longest measurement of the outlet. 

By most of the German obstetricians the influence of the ischial spines 
and of the smooth pelvic planes in producing rotation is not admitted. 
They rather refer the change of direction to the increased resistance the 
head meets from the posterior wall of the pelvis and from the perineal 
structures. AVhichever part of the head first meets this resistance, which 
is much greater than that of the anterior part of the pelvis, must neces- 
sarily be pressed forward ; and as, in the large majority of cases, the pos- 
terior fontanelle descends first, it is thus pressed forward until rotation 
is effected. This view has the advantage of accounting equally well for 
the rotation in occipito-posterior as in occipito-anterior positions, the 
former of which, on the more ordinarily received theory, are not quite 
satisfactorily explicable. It does not follow that the smooth surfaces of 
the pelvic planes are without influence in favoring the rotation. On 
the contrary, they doubtless greatly facilitate it ; and it is probable that 
both these agencies operate in producing anterior rotation of the occiput. 

In some rare cases the head escapes rotation and reaches the peri- 
neum still lying in the oblique diameter. Even here, however, rotation 
is generally effected, often suddenly,justasthe head is about to pass the 
vulva, and it is very rarely expelled in the oblique position. The 
movement at this stage may be explained by the perineum, which is 
attached at its sides and grooved in its centre : to the hollow so formed 
the long diameter of the head accommodates itself, and is tlius rotated 
into the antero-posterior diameter of the outlet. 

5. Exiensioii. — By the process just described the face is turned back 
into the hollow of the sacrum : but the head does not lie absolutelv in 



MECHANISM OF DELIVERY IN IIEAIJ PRESENTATION, 279 

the antero-posterior diameter of the pelvic outlet, but rather in one 
between it and the oblique. The occiput is still forced down by the 
pains, and in consequence of its altered position is enabled to pass 
between the rami of the pubis, and advances until its further descent is 
checked by the nape of the neck, which is pressed under and against the 
arch of the pubes. By this means the occiput is fixed, and the pains 
continuing, the uterine force no longer acts on the occiput, but on the 
anterior part of the head, which is now pushed down and separated from 
the sternum. This constitutes extension. As the head descends the soft 
structures of the perineum are stretched and the coccyx pushed back so 
as to enlarge the outlet. The pains continue to distend the perineum 
more and more, the head advancing and receding with each pain. As 
the forehead descends the suboccipito-bregmatic, the suboccipito-frontal, 
and the suboccipito-mental diameters successively present ; the occiput 

Fig. 103. 




First Position (o.l.a.) : Head Delivered. (After Hodge.) 

turns more and more upward in front of the pubes (Fig. 103), and at 
last the face sweeps over the perineum and is born. 

The mechanical cause of this movement may be readily explained. 
As soon as the occiput has passed under the arch of the pubes, and is 
no longer resisted by the anterior pelvic walls, the head is subjected to 
the action of two forces — that of the uterine pressure, acting downward 
and backward ; and that of i\\Q resistance of the posterior walls of the 
pelvis and the soft parts, acting almost directly forward. The neces- 
sary result is that the head is pushed in a direction intermediate between 
these two opposing forces — that is, downward and forward in the axis 
of the pelvic outlet. 

In addition to the slight obliquity which exists as regards the direct 
relation of the long diameter of i\\i:t head to the antero-posterior diam- 
eter of the outlet at the moment of its expulsion, the head also lies 
somewhat obliquely in relation to its own transverse diameter, so that 
in the majority of cases the right parietal bone is expelled before the 
left. 

6. External Rotation. — Shortly after the head is expelled, as soon as 
renewed uterine action commences it may be observed to make a di>tinet 
rotary movement, the oreiput turning to the left thigh oi' the mother 
and the face turning upward to the right tliigh (Fig. 104). Tiie reason 
of this is evident. AVhen the head descends in the right oblique diani- 



280 



LABOR. 



eter the shouldei's lie in the opposite or left oblique diameter, and, as 
the head rotates into the autero-posterior diameter, they are necessarily 
placed more nearly in the transverse. As soon as the head is expelled 
the shoulders are subjected to the same uterine force and pelvic resist- 



FiG. 104. 




External Rotation of Head in First Position (o.l.a.). (After Hodge.) 

ance as the head has just been, and they are acted on in precisely the 
same way. Consequently they too rotate, but in the opposite direction, 
into the antero-posterior diameter of the outlet, or nearly so, just as the 
head did, and as tliey do so they necessarily carry the head with them 
and cause its external rotation. 

The two shoulders are soon expelled, the left shoulder generally the 
first, sweeping over the perineum in the same manner as the face. This 
is, however, not always the case, and they are often expelled simulta- 
neously, or the right shoulder may come fii^t. The body soon follows, 
and the second stage of labor is completed. 

Second Position. — In the second position (o.d.a.) the long diameter 
of the head lies in the left oblique diameter of the pelvis. On making 
a vaginal examination in the ordinary obstetric position, the finger, 
passing upward and to the right, feels the small posterior fontanelle ; 
downward and to the left, it feels the anterior. The sagittal suture lies 
obliquely across the pelvis in the left oblique diameter. The description 
of the mechanism of delivery is precisely the same as in the first posi- 
tion (o.l.a.), substituting the word " left '^ for ^' right." Thus the finger 
impinges on the left parietal bone ; the occiput turns from right to left 
during rotation. After the birth of the head the occiput turns to the 
right thigh of the mother, the face to the left thigh. 

Third, or Bight Occipito-sacro-iliac Position. — In the third posi- 
tion (o.D.P.) the head enters the pelvic brim with the occiput directed 
backward to the right sacro-iliac synchondrosis, and the sinciput for- 
ward to the left foramen ovale (Fig. 105). The posterior fontanelle is 
directed backward, the anterior fontanelle forward, while the examining 
finger impinges on the left parietal bone. The mechanism of delivery 
in these cases is of much interest. In the large majority of cases dur- 



MECHANISM OF DELIVERY IN HEAD PRESENTATION. 281 

ing the progress of delivery the occiput rotates forward along the right 
side of the pelvis, until it comes to lie almost in the antero-posterior 
diameter of the outlet and passes under the pubic arch, the forehead 
passing over the perineum. It will be seen that during part of this 
extensive rotation the head must lie in the second position (o.d.a.), and 

Fi«. 105. 




Third Position (o.d.p.) of Occiput, at Brim of Pelvis. 

the case terminates just as if it had been in the second position (o.d.a.) 
from the commencement of labor. 

Manner in which the Occiput is Rotated Forward. — How is it 
that this rotation is effected, and that the sinciput, occupying the position 
of the occiput in the first position (o.l.a.), should not be rotated for- 
ward to the pubes, as that is ? This, no doubt, may be explained by the 
fact that the uterine force transmitted through the vertebral column 
causes the occiput to descend lower than the sinciput, so that in most 
cases in making a vaginal examination the posterior fontanelle can be 
readily felt, while the anterior is high up and out of reach. The head 
is therefore extremely flexed, and so descends into the pelvic cavity, 
until the occiput, being now below the right ischial spine, experiences 
the resistance of the pelvic floor opposite the right sacro-ischiatic liga- 
ment, by which it is directed forward. The forehead is, at this time, 
supposing flexion to be marked, too high to be influenced by the ante- 
rior pelvic plane. Pressure continuing, the occiput rotates forward, the 
forehead passes round the left side of the pelvis, and labor is terminated 
as in the second position (o.p.a). 

The period of labor at Avhich rotation takes place varies. In the 
majority of cases it does not occur until the head is on the lioor of the 
pelvis, for it is then that resistance is most felt ; but the greater the 
resistance the sooner will rotation be pnuhuvd. Hence it is more likely 
to occur early when the head is large and the pelvis comparatively 
small. 

The facility with which this movement is etVect«.\l obviously dojvnds 



282 LABOR. 

upon the complete flexion of the chin on the sternum, by which the 
anterior fontanelle is so elevated that its rotation backward is not resisted 
by the inward projection of the left ischial sj^ine, and the occiput is cor- 
respondingly depressed. If, however, this flexion is not complete, and 
the anterior fontanelle is so low as to be readily within reach of the 
finger, considerable difficulty is likely to be experienced. In many such 
cases rotation is still eventually effected, but in others it is not ; and the 
labor is then terminated Avith the face to the pubes, but at the expense 
of considerable delay and difficulty. According to Dr. Uvedale West 
of Alford, who devoted much careful study to the subject, this termi- 
nation occurs in about 4 per cent, of occipito-posterior positions. When 
it is about to happen the anterior fontanelle may be felt very low down, 
and sometimes even the forehead and superciliary ridges. The uterine 
force pushes down the occiput, the sinciput being fixed behind the 
pubes, which it obviously cannot pass under, as does the occi]3ut in the 
first position. The sinciput, therefore, becomes more flexed and pushed 
U23ward, while the resistance of the pelvic floor directs the occiput for- 
ward. The perineum now becomes enormously distended by the back 
part of the head, and is in great danger of laceration. The occiput is 
eventually, but not without much difficulty, expelled. A process of 
extension now occurs, the nape of the neck being fixed, as it wTre, 
against the centre of the perineum, the expelling force now acting on 
the forehead, and producing rotation of the head on its transverse axis* 
The forehead and face are thus protruded, and the body follows without 
difficulty. 

It is said that in a few exceptional cases, where the anterior fonta- 
nelle is much depressed, the labor may terminate by the conversion of 
the presentation into one of the face, the head rotating on its transverse 
axis, the forehead passing to the posterior part of the pelvis, and the 
chin emerging under the perineum. It is obvious, however, that this 
change can only occur when the head is unusually small, and it must 
of necessity be extremely rare. 

Reference has already been made to Xaegele^s views as to the rarity 
of the second position (o.d.a.), and to his opinion that cases in which 
the occiput was found to point to the right foramen ovale Avere only 
transitional stages in the rotation of occipito-posterior positions. Such 
an assumption, however, is unwarrantable, unless the case has been 
watched from the very commencement of labor. Many perfectly qual- 
ified observers have arrived at the conclusion that second positions 
(o.d.a.) are far more common than Xaegele supposed ; and in the table 
already quoted it Avill be seen that Avhile Murphy estimates the second 
(o.d.a.) and third (o.d.p.) as being equally frequent, SAvayne believes 
the second (o.d.a.) to be much more common than the third (o.d.p.). 
It is probable that the Aveight of Naegele's authority has induced many 
observers to classify second (o.d.a.) positions as third (o.d.p.) positions 
in Avhich partial rotation has already been accomplished. My own 
experience Avould certainly lead me to think that second (o.d.a.) posi- 
tions are very far from uncommon. The question, however, must be 
considered to be in abeyance until further obserA'ations by competent 
authorities enable us to decide it conclusivelv. 



MECHANISM OF DELIVERY IN HEAD PRESENTATION. 283 

Fourth or Left Occipito-sacro-iliac Position. — The fourth position 
(o.L.P.) is just as much the reverse of the second as the third is of the 
first. The occiput points to the left (Fig. 106) sacro-iliac synchondrosis, 

Fig. 106. 




Fourth Position (o.l.p.) of Occiput at Pelvic Brim. 

and the finger impinges on the right parietal bone. The mechanism is 
precisely the same as in the third position (o.d.p.), the rotation taking 
place from left to right. 

Formation of the Caput Succedaneum. — The formation of the 
caput succedaneum has been already alluded to. This term is applied 
to the oedematous swelling which forms on the head, and is produced 
by effusion from the obstruction of the venous circulation caused by the 
pressure to which the head is subjected. It follows that tixe size of the 
swelling is in direct proportion to the length of the labor. In rapid 
deliveries, in which the head is forced through the pelvis quickly, it is 
scarcely, if at all, developed ; while after protracted labor it i« large and 
distinct, and may obscure the diagnosis of the position by preventing 
the sutures and fontanelles being felt. Its situation varies according to 
the position of the head; thus, in the first (o.l.a.) and fourth (o.l.p.) 
positions it forms on the right parietal bone, in the second (o.d.a.) and 
third (o.d.p.) on the left ; and Ave may therefore verify by inspection 
of its site the accuracy of our diagnosis. 

An ordinary mistake wliich has been made by obstetricians is to 
regard the caput succedaneum as formed at the point where the head 
has been most subjected to pressure, while in fact it forms on that part 
which is most unsupported by the maternal structures, and where the 
swelling may consequently most readily occur. Therefore, in the early 
stages of the labor it always forms on the part of the head which lies 
in the cin^le of the os uteri, while in subsequent stages it tbrnis on that 
vvhich lies in the axis of the vaginal canal, and eventually is most 
prominent on the part that is first expelled from the vulva. 

Alteration in the Shape of the Head from Moulding*. — A tew 
words may be said as to the alteration in the form of the tanal head 
which occurs in tedious, labors, and r(\-iults from the moulding which it 
has undergone in its passage through the jielvis. The smaller the pelvis 
and the greater the pressure a{>plied to the head during the delivery, 



284 LABOR. 

the more marked is this. The result is that in vertex presentations the 
occipito-mental and occipito-frontal diameters are elongated to the 
extent of an inch or even more, while the transverse diameters are 
lessened from compression of the parietal bones. This moulding is 
of unquestionable value in facilitating the birth of the child. The 
amount of apparent deformity is very considerable, and may even give 
rise to some anxiety. It is well to remember, therefore, that it is 
always transient,., and that in a few hours, or days at most, the elasticity 
of the soft cranial bones causes them to resume their natural form. 
The caput succedaneum also disappears rapidly ; therefore no amount 
of deformity from either of these causes need give rise to anxiety or 
call for any treatment. 



CHAPTER III. 

MANAGEMENT OF NATURAL LABOR. 

Although labor is a strictly physiological function, and in a large 
majority of cases might, no doubt, be safely accomplished without assist- 
ance from the accoucheur, still, medical aid, properly given, is always 
of value in facilitating the process, and is often absolutely essential for 
the safety of the mother and child. 

Preparatory Treatment. — The management of the pregnant woman 
before delivery is a point which should always receive the attention of 
the medical attendant, since it is of consequence that the labor should 
come on when she is in as good a state of health as possible. For this 
purpose ordinary hygienic precautions should never be neglected in the 
latter months of gestation. The patient should take regular and gentle 
exercise short of fatigue, and, if the weather permit, should spend as 
much of her time as possible in the open air. Hot rooms, late hours, 
and excitement of all kinds should be strictly avoided. The diet 
should be simple, nutritious, and unstimulating. The state of the 
bowels should be strictly attended to. During the few days preceding 
labor the descent of the uterus often causes pressure on the rectum and 
prevents its evacuation. Hence it is customary to prescribe occasional 
gentle aperients, snch as small doses of castor oil, for a few days before 
the expected period of delivery. Some caution, however, is necessary, 
as it is certainly not very uncommon for labor to be determined rather 
sooner than was anticipated, in consequence of the irritation of too 
large a purgative dose. The state of tlie bowels should ahvays be 
inquired into at the commencement of labor, and, if there be any 
reason to suspect that they are loaded, a copious enema should be 
administered. This is always a proper precaution to take, for a loaded 
rectum is a common cause of irregular and ineifective uterine action ; 



MANAGEMENT OF NATURAL LABOR. 285 

and even when it does not produce this result, the escape of the feces 
in consequence of pressure on the bowel during the propulsive stage is 
always disagreeable both to the patient and practitioner. 

The dress of the patient during pregnancy may be here adverted 
to, for much discomfort may arise and the satisfactory progress of labor 
may even be interfered with from errors in this respect. 

After the uterus has risen out of the pelvis the ordinary corset which 
most women wear is apt to produce very injurious pressure ; still more 
so when attempts are made to conceal the increased size by tight lacing. 
After the fourth or fifth month, therefore, the comfort of the patient is 
much increased by wearing a specially-constructed pair of stays with 
elastic let into the sides and front, so that they accommodate them- 
selves to the gradual increase of the figure. Such are made by all stay- 
makers, and should be worn whenever the circumstances of the patient 
permit. Failing this, it is better to avoid the use of the corset 
altogether, and to have as little pressure on the uterus as possible, 
although many women cannot do without the support to which they 
are accustomed. To multiparse, especially if there be much laxity of 
the abdominal parietes, a well-fitting elastic abdominal belt is often a 
great comfort. This is constructed so that it can be tightened when the 
patient is walking and in the erect position, when such support is most 
required, and readily loosened when desired. 

Necessity of Attending- to the First Summons. — It is hardly 
necessary to insist on the necessity of the practitioner attending imme- 
diately to the first summons to the patient. It is true that he may very 
often be sent for long before he is actually required. But, on the other 
hand, it is quite impossible to foresee what may be the state of any in- 
dividual case. By prompt attention he may be able to rectify a mal- 
position or prevent some impending catastrophe, and thus save his 
patient from consequences of the utmost gravity. 

The practitioner should always be provided with the articles which 
he may require. The ordinary obstetric cases, containing one or two 
bottles and a catheter, such as are sold by most instrument-makers, are 
cumbrous and useless, while "obstetric bags'' are expensive luxuries 
not within the reach of all. Every one can manufacture an excellent 
obstetric bag for himself at a small expense by having compartments 
for holding bottles stitched on to the sides of an ordinary leather bag, 
such as is sold for a few shillings at any portmanteau-maker's. It is a 
great comfort to have at hand all that may be required, and the bag 
should contain chloroform or other anaesthetic, antiseptics in a concen- 
trated form, chloral, laudaniun, the liquor ferri perchloridi of the Phar- 
macopoeia, the liquid extract of ergot, and a hypodermic syringe, Avith 
bottles containing carbolized oil, ether, and a solution of crgotino for 
subcutaneous injection. If it also contain a Higginson's syringe, a 
small elastic catheter, a good })air of forcx^ps, and one or two suturo- 
needles, with some silver wire or carboli/od catgut, the practitioner is 
provided against any ordinary contingency. Other articles that may bo 
required, such as thread,* scissors, and the like, are generally providixl 
by the nurse or patient. 

Duties on First Visiting' the Patient. — On arriving at the house 



286 LABOR. 

the practitioner should have his visit announced to the patient, and he 
will very often find that the first effect of his presence is to arrest the 
pains that have been hitherto progressing rapidly, thereby affording a 
very conclusive proof of the. influence of mental impressions on the 
progress of labor. If the pains be not already propulsive, it is well 
that he should occupy himself at first in general inquiries from the 
attendants as to the progress of the labor, and in seeing that all the 
necessary arrangements are satisfactorily carried out, so as to allow the 
patient time to get accustomed to his presence. If he have any choice 
in the matter, he should endeavor to secure a large, airy, and well- 
ventilated apartment for the lying-in room, as far removed as possible 
from w^ithout. He may also see to the bed, which should be without 
curtains and prepared for the labor by having a waterproof sheeting 
laid under a folded blanket or sheet, on which the patient lies. These 
receive the discharges during labor, and can be pulled from under the 
patient after delivery, so as to leave the dry clothes beneath. [We 
would, in this connection, particularly recommend to accoucheurs the 
caoutchouc dam and apron devised as a protector and conduit by Prof. 
Howard A. Kelly of Philadelphia, as it not only prevents the soiling 
of the bed and the undergarments of the patient, but will admit of a 
reliable measurement of the amniotic fluid when in excess, and of that 
removed from the head by tapping in hydrocephalus. It has been 
found specially useful in cases of emergency and in practice among the 
poor and unprepared. — Ed.] Among the lower classes the lying-in 
chamber is considered a legitimate meeting-place for numerous female 
friends to gossip, whose conversation is often distressing, and is certainly 
injurious, to a woman in the excitable condition associated with labor. 
The medical attendant should therefore insist on as much quiet as pos- 
sible, and should allow no one in the room except the nurse and some 
one friend whose presence the patient may desire. The husband's 
presence must be left to the wishes of the patient. Some women 
like their husbands to be with them, while others prefer to be without 
them ; and the medical attendant is bound to act in accordance with the 
patient's desire. 

If pains be actually present a vaginal examination is essential, and 
should not be delayed. It enables us to ascertain whether the labor has 
commenced or not, and whether the presentation is natural or otherwise. 
The pains, although apparently severe, may be altogether spurious, and 
labor may not have actually commenced. It is of much importance, 
both for our own credit and comfort, that we should be able to diagnose 
the true character of the pains; for if they be so-called "false" pains, 
we might wait hours in fruitless expectation of progress, while delivery 
is still far off. The necessity of ascertaining, therefore, the actual state 
of affairs need not further be insisted on. [In this connection we 
desire to remind the obstetrician that the vagina of the patient and his 
own hands should be rendered aseptic before he employs his index finger 
in making "the touch." A physician with ozsena should never practise 
obstetrics, for fear of poisoning his patient by the touch after using his 
handkerchief. Many deaths have been in this way produced. — Ed.] 

False pains are chiefly characterized by their irregularity, sometimes 



MANAGEMENT OF NATURAL LABOR. 287 

coming on at short intervals, sometimes with many hours between 
them : they also vary much in intensity, some being very sharp and 
painful, while others are slight and transient. In these respects they 
differ from the true pains of the first stage, which are at first slight and 
short, and gradually recur Avith increased force and regularity. The 
situation of the two kinds of pains also varies, the false pains being 
chiefly situated in front, while the true pains are felt most in the back 
and gradually shoot round toward the abdomen. Nothing short of a 
vaginal examination will enable us to clear up the diagnosis satisfac- 
torily. If the labor have actually commenced, the os will be more or 
less dilated and its edges thinned, while with each pain the cervix will 
become rigid and the membranes tense and prominent. The false 
pains, on the contrary, have no effect on the cervix, which remains 
flaccid and undilated, or, if the os be sufficiently open to admit the tip 
of the finger, the membranes will not become prominent during the 
contraction. Under such circumstances we may confidently assure the 
patient that the pains are false, and measures should be taken to remove 
the irritation which produces them. In the large majority of cases the 
cause of the spurious pains will be found to be some disordered state of 
the intestinal tract; and they will be best remedied by a gentle aperient, 
such as castor oil or the compound colocynth pill with hyoscyamus, fol- 
lowed by or combined with a sedative, such as twenty minims of lauda- 
num or chlorodyne. Shortly after this has been administered the false 
pains will die away, and not recur until true labor commences. 

Mode of Conducting' a Vaginal Examination. — For a vaginal 
examination the patient is placed by the nurse on her left side, close to 
the edge of the bed, with the legs flexed on the abdomen. The practi- 
tioner, being seated by the edge of the bed, passes the index finger of 
the right hand, the proper antiseptic precautions having previously been 
taken, up to the vulva, and gently insinuates it into the orifice of the 
vagina, then pushes it backward in the axis of the vaginal outlet, and 
finally turns it upward and forward, so as to more readily reach the cer- 
vix (Fig. 107). This it may not always be easy to do, for at the com- 
mencement of labor the cervix may be so high as to be reached with 
difficulty, or it may be directed backward so as to point toward the 
cavity of the sacrum. The exploration is often much facilitated by 
depressing the uterus from without by the left hand placed on the abdo- 
men. Our object is not only to ascertain the state of the cervix as to 
softness and dilatation, but also the presentation, tlie condition of the 
vagina, and the capacity of the pelvis. The examination is generally 
commenced during a pain, at which time it is less depressing to the 
patient; but in order to be satisfactory the finger nuist remain in the 
vagina until the pain is over, the examination being concluded in the 
interval between this pain and the next. 

In head presentation the round mass of the cranium is generally at 
once felt through the lower part of the uterus, and then we have the 
satisfaction of l)eing able to assure the patient that all is right. It' the 
OS be sufficiently dilated,, we can also feel through it the occiput covoiwi 
by the membranes. It is impossible at this time to make owx the exact 
position of the head by means of the sutures and fontnnollos. \\\\w\\ 



288 LABOR. 

are too high up to be within reach. Xor should any attempt be made 
to do so, for fear of prematurely rupturing the membranes. The fact 
that the head is presenting is all that we require to know at this stage 
of the labor. 

The condition of the os itself as to rigidity and dilatation will 
materially assist us in forming an opinion as to the progress and proba- 

FiG. 107. 




Examination during the First Stage. 

ble duration of the labor ; but, although the friends will certainly press 
for an opinion on this point, the cautious practitioner will be careful 
not to commit himself to a positive statement which may so easily be 
falsified. It will suffice to assure the friends that everything is satis- 
factory, but that it is impossible to say with any certainty how^ rapidly 
or the reverse the case may progress. 

If the pains be not very frequent or strong, and the os not dilated to 
more than the size of a shilling, a considerable delay may be anticipated 
and the presence of the medical attendant is useless. He may therefore 
safely leave the patient for an hour or more, provided he be within 
easy reach. It is needless to say that this should never be done unless 
the exact presentation be made out. If some part other than the head 
be presenting, it will probably be impossible to make it out until dilata- 
tion has progressed further ; and the practitioner must be incessantly on 
the watch until the nature of the case be made out, so as to be able to 
seize the most favorable moment for interference, should that be necessary. 

Position of Patient during" First Stage. — The position of the 
patient is a matter of some moment in the first stage. It is a decided 
advantage that she should not be then in a recumbent position on her 
side, as is usual in the second stage ; for it is of importance that the 



MANAGEMENT OF NATURAL LABOR. 289 

expulsive force should a(;t in sucli a way as to favor the descent of tlie 
head into the pelvis — /. e. perpendicularly to the plane of its brim — and 
also that the weight of the child should operate in the same way. 
Therefore, the ordinary custom of allowing the patient to walk about 
or to recline in a chair is decidedly advantageous ; and it will often be 
observed that the pains are more lingering and ineffective if she lie in 
bed. If the patient be a multipara or if the abdomen be somewhat 
pendulous, an abdominal bandage, by supporting the uterus, will greatly 
favor the progress of this stage. Keeping the patient out of bed has 
the further advantage of preventing her being unduly anxious for the 
termination of the labor, and a little cheerful conversation will keep 
up her spirits and obviate the mental depression which is so common. 
Good beef-tea may be freely administered, with a little brandy and 
water occasionally if the patient be weak, and will be useful in sup- 
porting her strength. 

Over-frequent vaginal examinations at this period should be avoided, 
for they serve no useful purpose and are apt to irritate the cervix. It 
will be necessary, however, to ascertain the progress of the dilatation 
at intervals. 

When once the os is fully dilated the membranes may be artificially 
ruptured if they have not broken spontaneously, for they no longer 
serve any useful purpose and only retard the advent of the propulsive 
stage. This can be easily done by pressing on them, when they are 
rendered tense during a pain, by some pointed instrument, such as the 
end of a hairpin, which is always at hand. In some cases, indeed, it is 
even expedient to rupture the membranes before the os is fully dilated. 
Thus it not unfrequently happens, when the amount of liquor amnii is 
at all excessive, that the os dilates to the size of a silver dollar or 
more ; but, although it is perfectly soft and flaccid, it opens up no 
farther until the liquor amnii is evacuated, when the propulsive pains 
rapidly complete its dilatation. Some experience and judgment are 
required in the detection of such cases, for if ^ve evacuate the liquor 
amnii prematurely the pressure of the head on the cervix might pro- 
duce irritation and seriously prolong the labor. This manoeuvre is 
most likely to be useful when the pains are strong and the os perfectly 
flaccid, but when the membranes do not protrude through the os so as 
to effect further dilatation. 

It is sometimes not easy to ascertain whether the membranes are ruj)- 
tured or not. This is most likely to be the case when the head is low 
down and the amount of liquor anuiii is so small that the pouch does 
not become prominent during the pains. A little care, however, m ill 
enable us, if the membranes are I'uptured, to feel the rugosities of the 
scalp covered with hair, and to distinguish it from the smooth polished 
surface of the membranes. 

After the evacuation of the liquor anuiii there is generally a lull in 
the progress of the labor, the pains, however, soon recurring with in- 
creased force and frequency, and ])ropelling the head tlirough the ]vlvie 
cavity. The change in the character of the pains is soon n]t]MvciatiHi 
by the bearing-down eilbrts by which they are accompanied, as well as 
bv their increased lenoth and intensitv. 



290 LABOB. 

Position of the Patient during* the Second Stage. — It is now 
advisable that the ^^atient be placed in bed ; and in England it is 
usual for her to lie on her left side, with her nates parallel to the edge 
of the bed and her body lying across it. This is the established obstet- 
ric position in England, and it would be useless to attempt to insist on 
any other, even if it were advisable. Although the dorsal position is 
preferred on the Continent, it is difficult to see wherein its advantages 
consist. It certainly leads to unnecessary exposure of the person, and 
it is, on the whole, less easy to reach the patient so placed for the neces- 
sary manipulations. Moreover, the dorsal position increases the risk 
of laceration of the perineum by bringing the weight of the child's 
head to bear more directly upon it. Thus, Schroeder found that lacera- 
tions occurred in 37.6 per cent, of cases delivered on the back, as against 
24.4 per cent, in other positions. 

The patient usually remains in bed during the whole of this stage, 
and it is customary for the nurse to tie to the foot of the bed a jack- 
towel, which is laid hokl of and used as a support in making bearing- 
down efforts. If the pains be few and far between, and the patient 
finds it more comfortable to get up occasionally, there is no reason why 
she should not do so. On the contrary, as we shall subsequently see in 
treating of lingering labor, the pains under such circumstances are often 
increased in the sitting posture in consequence of the weight of the 
child producing increased pressure on the nerves of the vagina. 

At this time vaginal examination, which should be more frequently 
repeated than in the first stage, enables us to ascertain precisely the 
position of the head by means of the sutures and fontanelles, as well 
as to watch its progress. 

It not unfrequently happens that the head descends into the pelvis, 
even to its floor, without the os having entirely disappeared. The an- 
terior lip especially is apt to get caught between the head and pubes, 
to become swollen by the pressure to which it is subjected, and then to 
retard the progress of the labor. There can be no reasonable objection 
to attempting to prevent this cause of delay by pressing on the incar- 
cerated lip during the interval of the pains, so as to ])ush it above the 
head and maintain it there during the pains until the head descends 
below it. This manoeuvre, if done judiciously and without any undue 
roughness or force, is certainly not liable to be attended by any of the 
evil consequences which many obstetricians have attributed to it ; it is 
indeed a matter of common sense that the injury to the cervix is likely 
to be less if it be pushed gently out of the way than if it be left to be 
tightly jammed for hours between the presenting part and the bony 
pelvis. This mode of assistance is very difl'erent from the digital dila- 
tation of a rigid cervix, which was formerly much practised, especially 
in Edinburgh, in consequence of the recommendation of Hamilton, and 
which was properly objected to by the great majority of obstetricians. 

If the pains be producing satisfactory progress, no further interfer- 
ence is required. The medical attendant should, however, see that the 
bladder is evacuated, and if it have not been so for some hours it 
may be necessary to draw off the urine by the catheter. AVhenever 
the labor is lengthy he should occasionally practise auscultation, so 



MANAGEMENT OE NATURAL LABOR. 201 

as to satisfy liiinself that the foetal circulation is })eiiig satisfactorily 
carried on. 

The regulation of the bearing-down eiforts at this time is of import- 
ance. It is common for the nurse to urge the patient to help herself 
by straining, and it is certain that by voluntary action of this kind she 
can materially increase the action of the accessory muscles of parturi- 
tion. If the pains be strong and the labor promise to be rapid, such 
voluntary exertions are not likely to be prejudicial. On the other hand, 
if the cas'e be progressing slowly, they only unnecessarily fatigue the 
patient, and should be discouraged. When the perineum is distended 
we may even find it advisable to urge the patient to cease all voluntary 
effort and to cry out, for the express purpose of lessening the tension to 
which the perineum is subjected. This is the stage in which anaesthesia 
is most serviceable, but its employment must be separately discussed. 

Distension of the Perineum. — As the head descends more and more 
the perineum becomes distended, and there is considerable difference of 
opinion amongst accoucheurs as to the management of the case at this 
time. In most obstetric works the practitioner is advised to endeavor 
to prevent laceration by the manoeuvre that is described as ^' supporting 
the perineum.'' By this is meant laying the palm of the hand on the 
distended structures and pressing firmly upon them during the acme 
of the pain, with the view of mechanically ])reventing their tearing. 
There can be little doubt that this or some modification of it is the 
practice now followed by the large majority of practitioners. Of late 
years the evil effects likely to follow it have been specially dwelt upon 
by Graily Hewitt, Leishman, Goodell, and other writers, who maintain 
that by pressure exerted in this fiishion we not only fail to prevent, but 
actually favor, laceration, in consequence of the pressure producing 
increased uterine action just at the time when forcible distension of the 
perineum is likely to be hurtful. Therefore some hold that the peri- 
neum ought to be left entirely alone, and that the head should be allowed 
gradually to distend it, without any assistance on the part of the prac- 
titioner. 

Much error may be traced to a misconception of what is required. 
The term " supporting the perineum " conveys an unquestionably ei'ro- 
neous idea, and it is certain that no one can prevent laceration by 
mechanical support. If the term " relaxation of the perineum " was 
employed, we should have had a far more accurate idea of what shoukl 
be aimed at, and if this be borne in mind I think it cannot be ques- 
tioned that nature may be most usefully assisted at this stage. 

Dr. Goodell of Philadelphia has specially studiai this subject, and 
has recommended a method the object of which is to relax the per- 
ineum. His advice is that one or two fingers of the left hand should 
be inserted into the rectum, by which the }>erineum should be luH>kevl up 
and pulled forward over the head, toward the pubes, the ihunib ot" 
the same hand being placed on the advancing head, so as to restrain 
its ])rogress if needful. I have adopted this ])lan tVe(|uently. and 
believe tiiat it admirably answers its pur[)ose, especially wliou the 
perineum is greatly di*st(Muled and laceration is threatened. It nuist 
be admitted that the insertion of the tinoers into tiie anal oritiiv in 



292 



LABOR. 



the manuer recommended is repugnant both to the practitioner and 
tlie patient, and the same result can be obtained in a less unpleas- 
ant way. I mention it, however, to show what it is that the prac- 
titioner must aim at. If, when the head is distending the perineum 
greatly, the thumb and forefinger of the right hand are placed along 
its sides, it can be pushed gently forward over the head at the height 
of the pain, while the tips of the fingers may, at the same time, 
press upon the advancing vertex, so as to retard its progress if advisable 
(Fig. 108). By this means the sudden and forcible stretching of 

Fig. 108. 




Mode of effecting Relaxation of the Perineum. 



the perineal structures is prevented and the chance of laceration 
reduced to a minimum, while nature's mode of relaxing the tissues 
by dilatation of the anal orifice is favored. This is very different 
from the mechanical support that is usually recommended, and the 
less pressure that is applied directly to the perineum the better. Xor 
is it either needful or advisable to sit by the patient with the hand 
applied to the perineum for hours, as is so often practised. Time 
should be given for the gradual distension of the tissues by the alter- 
nate advance and recession of the head, and we need only intervene 
to assist relaxation when the stretching has reached its height and 
the head is about to be expelled. A napkin may be interposed between 
the hand and the skin for the purpose of cleanliness. Should the 
perineum be excessively tough and resistant, assiduous fomentation 
with a hot sponge may be resorted to, and will be of some service 
in promoting relaxation. 

Incision of the Perineum. — When the tension is so great that 
laceration seems inevitable it is wnerallv recommended that a slig-ht 
incision should be made on each side of the central raphe, with the 
view of preventing spontaneous laceration. This may no doubt be 



MANAGEMENT OF NATURAL LABOR. 293 

done with perfect safety, but I question if it is likely to be of use. 
The idea is that an incised wound is likely to heal more readily tlian 
a lacerated one. When, however, a distended perineum ruptures, its 
structures are so thinned that the tear is always linear, and as a 
matter of fact the edges of the tear are always as clean and as closely 
in apposition as if the cut had been made with a knife. Moreover, 
the laceration invariably heals perfectly if only the edges be brought 
into contact at once with one or two metallic sutures. I believe, 
therefore, that Goodell is right in stating that incision of the peri- 
neum is rarely if ever necessary, unless it is hardened by previous 
cicatrization. In almost all first labors the fourchette is torn, but 
requires no treatment of any kind. In some cases, do what w^e will, 
more or less laceration occurs, and the perineum should always be 
examined after the expulsion of the child to see if any tear has taken 
place. 

If it has given way to any extent, I believe that it is good prac- 
tice to insert one or two interrupted sutures of silver wire or car- 
bolized gut at once. Immediately after delivery the sensibility of the 
tissues is deadened by the distension to which they have been sub- 
jected, and the sutures can be inserted with little or no pain. It 
is quite true that lacerations of an inch or less will generally heal 
perfectly well of themselves ; but this is not invariably the case, wdiile 
healing almost certainly follows if the edges be brought together at 
once. In the severer forms of laceration, extending back to, or even 
through, the sphincter, the precaution is all the more necessary, and a 
subsequent more serious operation may in this way be avoided. The 
sutures can be removed without difficulty in a week or so, Avhen com- 
plete adliesion has taken place. 

Expulsion of the Child. — The head, when expelled, should be 
received in the palm of the right hand, while the left hand is placed 
upon the abdomen to follow down the uterus as it contracts and expels 
the body. There is generally some little delay after the expulsion of 
the head, and w^e should now see if the cord surround the neck, and if 
it does so it should be drawn over the head, and, if this is not possible, 
it may be tied and divided between the ligatures. Tlie expulsion of 
the body should be left entirely to the uterine contractions. If there 
be undue delay, we may endeavor to excite uterine action by friction 
on the fundus, and it will rarely happen that sufficient contraction does 
not now come on. If we display undue haste in withdrawing the 
body, we run the risk of em})tying the uterus while its tissues are 
relaxed, and so favor heuiorrhage. If, however, there seem serious 
danger of the child being asphyxiated, its expulsion mav be favored 
by gently passiug the forefinger of each hand within tlie axilhv aud 
using traction ; but it is only very exceptionally that such interterenee 
is required. 

Promotion of Uterine Contraction after the Birth of the Child. 
— As the uterus contracts it should be carefully followeil down through 
the abdominal pariete;^ by the left hand, which should grasp it as the 
body is expelled, with the view of seeing that it is efficiently coiuraeti\l. 



294 LABOR. 

This is a point of vital importance in preventing hemorrhage, which 
will presently be more especially considered. 

As soon as the child cries we may proceed to tie and separate the cord. 
For this purpose the nurse usually provides ligatures composed of sev- 
eral strands of whitey-brown thread, but tape or any other suitable 
material may be employed. It is important, especially if the cord be 
very thick and gelatinous, to see that it is thoroughly compressed, so 
that the vessels are obliterated, otherwise secondary hemorrhage might 
occur. The cord is tied about an inch and a half from the child, and 
it is usual — though, of course, not essential — to place a second ligature 
about two inches nearer the placental extremity of the cord. The latter 
is perhaps of some use by retaining the blood, and thus increasing the 
size of the placenta and favoring its more ready expulsion by uterine 
contraction. The cord is then divided with scissors between the liga- 
tures, the child wraj^ped up in flannel and given to the nurse or to a 
bystander to hold, while the attention of the practitioner is concentrated 
on the mother, with a view to the proper management of the third 
stage of labor. The researches of Budin,^ Ribemont,^ and others show 
that there is a distinct advantage in not tying the cord until the child 
has cried lustily, as the act of respiration tends to withdraw the placen- 
tal blood, and thus increases the entire amount of blood in the foetus. 
It is said that after late ligature of the cord the child is more vigorous 
and active than when it is tied too early. 

The cord may, if preferred, be treated with perfect safety by lacera- 
tion. This method was first brought under my notice by my friend Dr. 
Stephen, who has employed it for many years and in several hundred 
cases. The cord is twisted round the index fingers of both hands and 
torn through, the lacerated vessels retracting without any hemorrhage. 
It is a close imitation of the metliod instinctively adopted by the lower 
animals, who gnaw^ the cord asunder, and has the advantage of dis- 
pensing with ligatures altogether. I have used it myself in a large 
number of cases, but prefer, on the whole, the plan usually adopted. 

Importance of Proper Manag-ement of Third Stag-e. — There is 
unquestionably no period of labor where skilled management is more 
important, and none in which mistakes are more frequently made. By 
proper care at this time the risk of post-partum hemorrhage is reduced 
to a minimum, the efficient contraction of the uterus is secured, the 
amount and intensity of after-pains are lessened, and the safety and 
comfort of the patient greatly promoted. Moreover, the general prac- 
tice as to the management of this stage is opposed to the natural mechan- 
ism of placental expulsion, and is far from being well adapted to secure 
the important objects which we ought to have in view. Let us see Avhat 
is the practice usually recommended and followed, and then we shall be 
in a position to understand in what respects it is erroneous. For this 
purpose I cannot do better than copy the directions contained in one of 
our most deservedly popular obstetric textbooks, which undoubtedly 
expresses the usual practice in the management of this stage : " When 
the binder is applied the patient may be allowed to rest a while if there 

^ Bndin, Progres medical 1876, torn. iv. pp. 2, 36. 

2 Archil', de Tocologie, 1879, p. 577. 



MANAGEMENT OF NATURAL LABOR. 295 

is no flooding; after which, wlien the utcruH contraetH, gontlo traction 
may be made by the funis to ascertain if the placenta be detached. If 
so, and especially if it be in the vagina, it may be removed by continu- 
ing the traction steadily in the axis of the upper outlet at first, at the 
same time making pressure on the uterus." ^ 

[In this country, for many years, the uniform teaching has been that 
the binder should not be ap})lied until the uterus has expelled the pla- 
centa and become firmly contracted. Although the plan of expression 
was not carried out as completely as is now taught under the Crede 
method, that of stimulating the contractions of the uterus by manipula- 
tion and pressure was certainly in use forty years ago. When the size 
and solidity of the uterus, as ascertained by the compressing hand, indi- 
cate that the placenta has been expelled into the vagina, it is a question 
whether we shall cause it to be forced through the vulva by pressing 
down the uterus upon it, or make traction upon it by the finger hooking 
down its edge. Occasionally, we find a patient who is very sensitive to 
pressure made upon her uterus after it has become firmly contracted ; 
and in such a case it may be well to depend partly upon traction for 
completing the delivery of the secundines. That it is possible for the 
uterus to expel the placenta suddenly from the vagina where no pressure 
has been made is evident from the fact that a physician of this city, who 
was making traction upon the cord under the old method some years 
ago, was surprised to find the placenta shoot out from the vulva and 
dangle by the funis as lie held it in his hand. In such a case the uterus 
must have been aided during a contraction by voluntary abdominal 
pressure, causing the os to descend nearly to the vulva. It is very evi- 
dent that the uterus is subject to muscular fatigue and to the exhaustion 
of its contractile power when long in action ; hence there is a greater 
risk of uterine atony and hemorrhage after a long labor than a short 
one, and we may expect a more complete expulsion of the placenta in 
the latter. It is also clear, from cases in my own experience, that the 
muscular power of the uterus is by no means in proportion to the gen- 
eral strength of the woman. The power to assist by bearing down no 
doubt is, but the independent power of the organ itself does not appear 
to be. Certainly some of the most perfect in parturient power that 
have come under my care were small w^omen with little general nuis- 
cular force. One little Avoman of 86 pounds weight api)oarod almost 
to have escaped the curse pronounced \\\)(m Eve ; and another, still 
smaller, expelled a placenta from her vaoina almost without anv loss 
of blood.— Ed.] 

This may fairly be taken as a sufiiciently accurate description o^ the 
practice usually followed. The objections I have to make are: (1) 
That it inculcates the connnon error of relying on the binder as a means 
of promoting uterine contraction, advising its a})})lication bef>re the 
expulsion of the placenta, while I hold that the binder sliould never be 
a})plied until after the placenta is expelled, and not even then unless tiio 
uterus is perfectly and perm:uiently contrat'ted. (*J) That it teaches that 
traction on the cord should be used as a means of withdrawing the pla- 
centa ; whereas the uterus itself should be made to expel the at'ter-birth, 

^ Clum-hiirs Theory and rradur of Midici/cni, p. 1(>'J. 



296 



LABOR. 



and in nineteen cases out of twenty the finger need never be introduced 
into the vagina after the birth of the child, nor the cord touched. This 
may seem an exaggerated statement to those who have accustomed 
themselves to the usual method of dealing with the placenta, but I feel 
confident that all who have learnt the method of expression of the 
placenta would testify to its accuracy/ 

Expression of the Placenta : its Object. — The cardinal point to 
bear in mind is, that the placenta should be expelled from the uterus by 
a vis a tergo, not drawn out by a vis a fronte. That uterine pressure 
after the birth of the child has been recommended by many English 
writers is certain, and the Dublin school especially have dwelt on its 
importance as a preventive of post-partum hemorrhage ; but the distinct 
enunciation of the doctrine that the placenta should be pressed, and 
not drawn, out of the uterus, we owe to Crede and other German 
Avr iters, and it is only of late years that this practice has become at all 
common. Those who have not seen placental expression practised find 
it difficult to understand that in the large majority of cases the uterus 
may be made to expel the placenta out of the vagina ; but such is 
unquestionably the fact. A little practice is no doubt necessary to eifect 
this satisfactorily, but w^hen once the knack has been learnt there is little 
difficulty likely to be experienced. 

Before describing the method of placental expression a word of cau- 
tion may be said against undue haste in attempting expression of the 
placenta — a mistake that is often made, and which, I believe, tends to 
increase the risk of post-partum hemorrhage. So long as we satisfy 
ourselves that the uterus is fairly contracted, so as to avoid the possi- 

^ This practice is further illustrated by the annexed diagram, contained in most 

Fig 109. 




Usual Method of Remo^^ng the Placenta by Traction on the Cord, 
obstetric works, which represents the accoucheur as withdrawing the placenta by trac- 
tion, and which I insert as an illustration of what ought not to be done (Fig. 109). 



MANAGEMENT OF NATURAL LABOR. 207 

bility of its distension with blood, a certain delay after the birth of the 
child is useful, from its giving time for coagula to form within the 
uterine sinuses by which their open mouths are closed. The importance 
of this point has been specially dwelt upon by McClintock, who lays 
down the rule that fifteen or twenty minutes should be allowed to elapse 
after the birth of the child before any attempt to remove the after-birth 
is made. This is a good and safe practical rule, as it gives ample time 
for the complete detachment of the placenta and the coagulation of the 
blood in the uterine sinuses. 

During this interval the practitioner or nurse should sit by the bed- 
side, with the hand on the uterus to secure contraction and prevent dis- 
tension, but not kneading or forcibly compressing it. When we judge 
that a sufficient time has elapsed we may proceed to effect expulsion. 
For this purpose the fundus should be grasped in the hollow of the left 
hand, the ulnar edge of the hand being well pressed down behind the 
fundus, and lohen the uterus is felt to harden strong and firm pressure 
should be made downward and backward in the axis of the pelvic brim. 
If this manoeuvre be properly carried out and sufficiently firm pressure 
made, in almost every case the uterus may be made to expel the placenta 
into the bed, along with any coagula that may be in its cavity (Fig. 
110). The uterine surface of the placenta is generally expelled first, as 

Fig. 110. 




niustniting Expression of the riacenta. 

is represented in the diagram, the cord being within the membranes ; 
whereas the foetal surface and root of the cord are the parts which appear 
first when the placenta is removed by traction (Fig. ^Od). If we do not 
succeed at the first efi'ort — which is rarely tlie ease if extrusion be not 
attempted too soon after the birth of the child — we mav wait until 
another contraction takes place, and then reapply the pressure. 1 repeat 
that after a little practice, the placenta may be entirely expelled in this 
way in nineteen cases out of twenty, without (>von tout-liino- ihe cowl, and 
the bugbear of retained placenta will ec^ase to be a source ot' dread. 



298 LABOR. 

Should we fail in causiDg the uterus to expel the placenta, a vaginal 
examination may be made, and if the placenta be found lying entirely 
in the vagina it may be carefully withdrawn. If, however, the cord 
can be traced up through the os, showing that the placenta is still Avith- 
in the uterine cavity, we must again resort to pressure to effect its 
expulsion, and not to attempt to withdraw it by traction. Such cases 
may fairly be classed as retained placenta, but they should be very 
rarely met with, and are discussed elsewhere. When they do occur 
often in the hands of the same practitioner, it is fair to conclude that 
he has not properly acquired the art of managing this stage of labor. 
Generally speaking, the placenta should be expelled within twenty 
minutes after the birth of the child, but no doubt in the large majority 
of cases expulsion might be effected sooner were it advisable to attempt it. 

Manag-eraent of the Membranes. — When the mass of the placenta 
is expelled the membranes generally still remain in the vagina, and they 
should be twisted into a rope and very gently withdrawn, so as not to 
leave any portion behind. This is a precaution the importance of 
which I would strongly urge, for I believe that the chance of part of 
the membranes being torn off and left in utero is the one objection to 
the method recommended. With due care, however, this accident may 
be avoided, and the risk will be lessened if the placenta is received into 
the palm of the right hand on expression, so as to avoid any strain on 
the membranes. 

The duties of the medical attendant are not even now over. For at 
least ten minutes after the extrusion of the placenta he should keep his 
hand on the firmly-contracted uterus, gently kneading it, without any 
force, for the purpose of promoting firm and equable contraction and 
causing it to throw off the coagula that may form in its cavity. 

The subsequent comfort and safety of the patient may be promoted 
by administering at this time a full dose of ergot of rye, such as a 
drachm or more of the liquid extract. The property possessed by this 
drug of producing tonic and persistent contraction of the uterine fibres, 
which renders it of doubtful utility as an oxytocic during labor, is 
of special value after delivery, when such contraction is precisely Avhat 
we desire. I have long been in the habit of administering the drug at 
this period, and believe it to be of great value, not only as a prophy- 
lactic against hemorrhage, but as a means of lessening after-pains. 

Application of the Binder. — When we are satisfied that the uterus 
is permanently contracted we may apply the binder, but this should 
rarely be done until at least half an hour after the birth of the child. 
The soiled clothes should be gently withdrawn from under the patient, 
moving her as little as possible, and the binder should be at the same 
time slipped under the body, taking care that it is passed well below 
the hips, so as to secure a firm hold. No kind of bandage is better than 
a piece of stout jean of sufficient breadth to extend from the trochanters 
to the ensiform cartilage ; a jack-towel or bolster slip answers the pur- 
pose very well. These are preferable, at any rate at first, to the shaped 
binders that are often used. One or two folded napkins are generally 
placed over the uterus, so as to form a pad to keep up pressure. Once 
in position, the binder is pulled tight and fastened by pins. The utility 



ANJESTHESIA IN LABOR. 209 

of careful bandaging after delivery can scarcely be doubted, although 
some years ago it became the fashion to dispense with it. It gives a 
comfortable support to the lax abdominal walls, keeps up a certain 
amount of pressure on the uterus, and tends to restore the figure of 
the patient. After the bandage is applied a warm napkin should be 
placed on the vulva, as a means of estimating the quantity of the dis- 
charge, and the patient may be allowed to rest. 

After-treatment. — Unless the labor has been very long and fatigu- 
ing an opiate, often exhibited as a matter of routine, is unadvisable, 
although it may be well to leave one with the nurse, to be given if the 
patient cannot sleep or if the after-pains be very troublesome. The 
practitioner may now leave the room, but not the house, and at least 
an hour should elapse after delivery before he takes his departure. 
Before doing so he should visit the patient, inspect the napkin to see 
that there is not too much discharge, and satisfy himself that the uterus 
is contracted and not distended with coagula. He should also count the 
pulse, which, if the patient be progressing satisfactorily, w^ill be found 
at its normal average. If, however, it be beating over one hundred per 
minute, he should on no account leave, for such a rapidity of the cir- 
culation renders it extremely probable that hemorrhage is impending. 
This is a good practical rule, laid down by McClintock in his excellent 
paper On the Pulse in Childbed, attention to which may often save the 
patient from disastrous consequences. 

Before leaving the practitioner should see that the room is darkened, 
all bystanders excluded, and the patient left as quiet as possible to 
recover from the shock of labor. 



CHAPTER IV. 

ANAESTHESIA IN LABOR. 

A FEW words may be said as to the use of aucTsthetics during labor — 
a practice which has become so universal that no argument is rotpiirod 
to establish its being a })erfectly legitimate means of assuaging the suf- 
ferings of childbirth. Indeed, the tendency in the present day is in the 
opposite direction, and a common error is the administration of chUu'o- 
form to an extent which materially interferes witli the uterine contrac- 
tions and predisposes to subsecjuent post-])artum hemorrhage. 

Ag-ents Employed. — Practically speaking, the only agent hitherto 
em})loyed in .England is chloroform, altlioiigh the bichloride o[ 
methyliMie and ether have been occasionally tried. Ot' hue yoars 
chloral has been extensively used by some, and, as 1 believe it u^ be 
an agent of very great value, I shall tirst indicate the circuni>ianivs 
under which it may be employed. 



300 LABOR. 

The peculiar value of chloral in labor is that it may be safely admin- 
istered at a time when chloroform cannot be generally employed. The 
latter, while it annuls suffering, very frequently tends in a marked 
degree to diminish uterine action. This is a familiar observation to 
all who have employed it much during labor, as the diminution of the 
force and intensity of the pains, and the consequent retardation of the 
labor, often oblige us to suspend its inhalation, at least temporarily. 
Indeed, this very property of annulling uterine action is one of its 
most valuable qualities in obstetrics, as in certain cases of turning. 
For such purposes it is necessary to give it to the surgical extent, 
which we endeavor to avoid when it is used simply to lessen the suf- 
fering of ordinary labor. Still, it is not always easy to limit its action 
in this way, and thus it very frequently does more than we wish. Such 
diminution in the intensity of uterine contraction is comparatively of 
less consequence in the propulsive stage, and it is generally more than 
counterbalanced by the relief it affords. In the first stage it is other- 
wise, and, practically speaking, chloroform is generally not admissible 
until the head is in the pelvic cavity. 

Chloral, on the other hand, has no such relaxing effects on uterine con- 
traction. It cannot, it is true, compete with chloroform in its power of 
relieving pain, but it produces a drowsy state in which the pain is not 
felt nearly so acutely as before. It is therefore in the first stage of 
labor, while the pains are cutting and grinding, and during the dilata- 
tion of the cervix, that it finds its most useful a23plication. It is 
especially valuable in those cases, so frequently met with in the upper 
classes, in which the pains produce intolerably acute suffering, but with 
little effect on the progress of the labor. In them the os is often thin 
and rigid and the pains very frequent and acute, but little or no dila- 
tation is effected. When the patient is brought under the influence of 
chloral, however, the pains become less frequent, but stronger, nervous 
excitement is calmed, and the dilatation of the cervix often proceeds 
rapidly and satisfactorily. Indeed, I know of nothing which answers 
so well in cases of rigid, undilatable cervix, and I believe its adminis- 
tration to be far more effective under such circumstances than any of 
the remedies usually employed. 

The object is to produce a somnolent condition which shall be pro- 
tracted as long as possible. For this purpose fifteen grains of chloral 
may be administered every twenty minutes until three doses are given. 
This generally suffices to produce the desired effect. The patient be- 
comes very drowsy, dozes between the pains, and wakes up as each 
contraction commences. It may be necessary to give a fourth dose at 
a longer interval, say an hour after the third dose, to keep up and pro- 
long the soporific action ; but this is seldom necessary, and I have 
rarely given more than a drachm of chloral during the entire progress 
of labor. Another advantage of this treatment is that, while it does 
not interfere with the use of chloroform in the second stage, it renders 
it necessary to give less than otherwise would be called for, and thus 
its action can be more easily kept within bounds. On the whole, there- 
fore, I am inclined to consider chloral a very valuable aid in the man- 
agement of labor, and believe that it is destined to be much more 



ANAESTHESIA IN LABOR, 301 

extensively used than is at present the case. So far as my experience 
has yet gone, I have not met with any symptoms which have led me 
to think that it has produced bad effects; and I have known many 
patients sleep quietly through labor, without expressing any excessive 
suffering or asking for chloroform, who under ordinary circumstances 
would have been most urgently calling for relief. It occasionally hap- 
pens that the patient cannot retain the chloral, from its tendency to pro- 
duce sickness ; it may then be readily given per rectum in the form of 
enema. 

Generally speaking, we do not think of giving chloroform until the 
OS is fully dilated, the head descending, and the pains becoming pro- 
pulsive. It has often, indeed, been administered earlier for the purpose 
of aiding the dilatation of a rigid cervix, and there is no doubt that it 
often succeeds well when employed in this way ; but I have already 
stated my belief that chloral answers this purpose better. 

There is one cardinal rule to be remembered in giving chloroform 
during the propulsive stage, and that is that it should be administered 
intermittently and never continuously. When the pain comes on a few 
drops may be scattered over a Skinner's inhaler, which affords one of 
the best means of administering it in labor, or placed within the folds 
of a handkerchief twisted into the form of a cone. During the acme of 
the pain the patient inhales it freely, and at once experiences a sense 
of great relief; and as soon as the pain dies away the inhaler should 
be removed. In the interval between the pains the effect of the drug 
passes off, so that the higher degree of anaesthesia should never be pro- 
duced. Indeed, when properly given consciousness should not be 
entirely abolished, and the patient between the pains should be able to 
speak and understand what is said to her. This intermittent adminis- 
tration constitutes the peculiar safety of chloroform administered in 
labor, and it is a fortunate circumstance that as yet there is, I believe, 
no case on record of death during the inhalation of chloroform for 
obstetric purposes. [^] This is obviously due to the effect of each inhala- 
tion passing off before a fresh dose is administered. 

The effect on the pains should be carefully watched. If they become 
very materially lessened in force and frequency, it may be necessary to 
stop the inhalation for a short time, commencing again when the pains 
get stronger : this effect may be often completely and easily prevented 
by mixing the chloroform with about one-third of absolute alcohol, 
which, originally recommended, I believe, by Dr. Sansom, increases the 
stinudating effects of chloroform and thus diminishes its tendency to 
produce undue relaxation. The amount administered nuist vary, of 
course, with the peculiarities of each individual case and the effect 
produced, but it need never be large. As the head distends the ]HTi- 
neum and the pains get very strong and forcing, it may be given nu»re 
freely and to the extent of inducing even complete insensibility just 
before the child is born. 

\} Prof. Plavfiiir may iind iive cases of chloroform-poisoninii- in olwtotrioal oases. \\'\\\\ 
two deaths, repcn-teci by Pn^t'. Lusk in the TmnMiction^ of the Auurican Oi/ihroiouic^il 
Societi/ for the year 1877. Three of the patients were saved through artitieial respira- 
tion. — IjD.] 



302 LABOR. 

Ether. — In cases in which chloroform has lessened the force of the 
pains ether may be given instead with great advantage. It certainly 
often acts well when chloroform is inadmissible on account of its effects 
on the pains^ and, so far as my experience goes, it has not the property 
of relaxing the uterus, but, on the contrary, has sometimes seemed to 
me distinctly to intensify the pains. Of late I have used a mixture of 
one part of absolute alcohol, two of chloroform, and three of ether. 
This is less disagreeable than ether, and has not the over-relaxing 
effects of chloroform. 

Bearing in mind the tendency of chloroform to produce uterine 
relaxation, more than ordinary precautions should always be taken 
against post-partum hemorrhage in all cases in which it has been 
freely administered. 

In cases of operative midwifery it is often given to the extent 
of producing complete anaesthesia. In all such cases it should be 
administered, when possible, by another medical man, and not by the 
operator, because the giving of chloroform to the surgical degree re- 
quires the undivided attention of the administrator, and no man can 
do this and operate at the same time. I once learnt an important lesson 
on this point. I had occasion to ap2)ly the forceps in the case of a lady 
who insisted on having chloroform. When commencing the operation 
I noticed some suspicious appearances about the patient, who was a 
large, stout woman with a feeble circulation. I therefore stopped, 
allowed her to regain consciousness, and delivered her without anaes- 
thesia, much to her own annoyance. Just one month after labor she 
went to a dentist to have a tooth extracted, and took chloroform, dur- 
ing the inhalation of which she died. This impressed on my mind the 
lesson that no man can do two things at the same time. The partial 
unconsciousness of incomplete anaesthesia, in which the patient is rest- 
less and tossing about, renders the application of forceps as well as all 
other operations very difficult. Therefore, unless the patient can be 
completely and fully anaesthetized, it is better to operate without chloro- 
form being given at all. 

[In the United States the dangers attending the use of chloroform 
in obstetric practice have, in large measure, banished it from the lying- 
in chamber. Some obstetricians in our chief cities still resort to it with 
little hesitation, believing that by great carefulness in its administration, 
and by the substitution of ether in exceptional cases, all danger may be 
avoided. Others have a very great fear of it, and universally trust to 
the safer anaesthetic. It is an error to suppose that the parturient state 
robs chloroform of much of its danger, the apparent immunity being 
due to its intermittent and incomplete administration ; complete anaes- 
thesia being but a fraction less dangerous than in surgical operations 
upon women who are not pregnant. Dr. Lusk, already quoted, after a 
large experience with the use of chloroform, says : " Patients in labor 
do not enjoy any absolute immunity from the pernicious effects of chloro- 
formJ^^ It is much to be regretted that this more pleasant anaesthetic 
is so much more dangerous than ether as an inhalant ; but in considera- 
tion of the difference of risk, that of their relative effects upon the nose 

[^ Opus cit.'] 



PELVIC PRESENTATIONS. 303 

and trachea is scarcely to be considered. Cliloroform acts upon the 
respiratory centres just as ether does ; and this is an element of danger 
in each, but is capable of being counteracted by artificial res])iration. 
But, beyond this, chloroform is far more dangerous, in acting uj)on tlie 
motor ganglia of the heart and producing sudden death. According 
to the experiments of Vulpian upon animals, not more than one case 
of cardiac failure in forty can be restored by artificial respiration. He 
affirms that there is danger at the commencement, during the course, 
and at the close of chloroforniization, and even some hours or days 
subsequent to it. Nelaton made the important discovery that the 
cerebral anaemia produced by chloroform, with its accompanying death- 
like condition, might be remedied by long perseverance in artificial res- 
piration with the patient turned head downward. 

Anaesthesia in labor is much less popular, both with obstetricians and 
patients in this country, than it was soon after its introduction. Im- 
provements in the purity of sulphuric ether have made the narcosis 
more reliable, but the general effect upon patients varies very decidedly, 
being all that can be desired in some, and just the reverse in others. 
Some of the undesirable effects I have witnessed are intoxication, with 
cessation of labor, hysterical excitement, nightmare, and post-partum 
inertia and hemorrhage. I have also witnessed the most delightful 
results from ether that could be desired. In a small, delicate multip- 
ara, whose mother died of phthisis, and to whom I had been obliged 
to administer stimulants in the first and much of the second stage of 
labor, the use of ether had the effect to revolutionize her condition. 
Her pulse became strong ; her expulsive power increased ; she had no 
suffering ; her placenta was expelled without accompanying blood ; and 
there was no subsequent uterine relaxation. But such cases are, unfor- 
tunately, exceptional. — Ed.] 



CHAPTER Y. 

PELVIC PRESENTATIONS. 

Under the head of pelvic presentations it is customary to include 
all cases in which any ]>nrt of the hnvor extremities of the child })rcsent8. 
By some these are further subdivided into breech, footliiu/, and kmr 
presentations; but, although it is of consequence to be able to reci>gnize 
the feet and the knee when they present, so far as the mechanism and 
management of delivery arc concerned the cases are identical, and then^ 
fore may be most conveniently considered together. 

Frequency. — Presentations comino- under this head are far Uom 



304 LABOR. 

uncommon : those in wliicli the breech alone occupies the pelvis are 
met with, according to Churchill, once in 52 labors, while Ramsbotham 
estimates that it presents more frequently — viz. once in 38.8 labors. 
Footling presentations occur only once in 92 cases. They are probably 
often the mere conversion of original breech presentations, the feet hav- 
ing come clown during the labor, either in consequence of the sudden 
escape of the liquor amnii, vrhen the breech was still freely movable 
above the brim, or from some other cause. Knee presentations are 
extremely rare, as may be readily understood if it be borne in mind that 
to admit them the thighs must be extended, hence the vertical measure- 
ment of the child must be greatly increased, and therefore it could not 
be readily accommodated within the uterine cavity unless of unusually 
small size. As a matter of fact, Mme. LaChapelle found only one knee 
presentation in upward of 3000 cases. 

The causes of pelvic presentations are not known. They are prob- 
ably the same as those which produce otlier varieties of malpresenta- 
tions, especially an excess of liquor amnii and slight pelvic contraction ; 
and it is not unlikely that in certain women there may be some pecu- 
liarity in the shape of the uterine cavity which favors their production. 
It would be difficult otherwise to explain such a case as that mentioned 
by Velpeau in which the breech presented in six labors. 

Prog-nosis. — The results as regards the mother are in no way more 
unfavorable than in vertex presentations. The first stage of the labor 
is generally tedious, since the large rounded mass of the breech does not 
adapt itself so well as the head to the lower segment of the uterus, and 
dilatation of the cervix is consequently apt to be retarded. The second 
stage is, however, if anything, more rapid than in vertex cases ; and 
even when it is protracted the soft breech does not produce such inju- 
rious pressure on the maternal structures as the hard and unyielding 
head. 

The result is very different as regards the child. Dubois calculated 
that 1 out of 11 children was stillborn. Churchill estimates the mor- 
talitv as much hisrher — viz. 1 in S\. The latter certainlv indicates a 
larger number of stillbirths than is consistent with the experience of 
most practitioners, and more than should occur if the cases be properly 
managed ; but there can be no doubt that the risk to the child is, even 
under the most favorable circumstances, very great. Even when the 
child is not lost it may be seriously injured. Dr. Ruge has tabulated 
a series of 29 cases in which there were found to be fractures of bones 
or other injuries.^ 

The chief source of danger is pressure on the umbilical cord in 
tlie interval elapsing between the birth of the body and the head. 
At this time the cord is very generally compressed betAveen the head of 
the child and the pelvic walls, so that circulation in its vessels is arrested. 
Hence the aeration of the foetal blood cannot take place, and pulmonary 
respiration not having been yet established, the child dies asphyxiated. 
There are other conditions present Avhich tend, although in a minor 
degree, to produce the same result. One of these is that the placenta 
is probably often separated by the uterine contractions when the bulk 
^ Bull. gen. de Therap., August, 1875. 



PELVIC PRESENTATIONS. 305 

of the body is being expelled, as, indeed, takes place under analogous 
circumstances when the vertex presents, the necessary result being 
the arrest of placental respiration. Joulin thinks that the same effect 
may be produced by the compression of the placenta between the con- 
tracted uterus and the liard mass of the foetal skull. Probably all these 
causes combine to arrest the functions of the placenta ; and if the deliv-- 
ery of the head, and consequently the establishment of pulmonary res- 
piration, be delayed, the death of the child is almost inevitable. The 
corollary is that the danger to the child is in direct proportion to the 
length of time that elapses between the birth of the body and that of the 
head. 

The risk to the child is greater in footling than in breech casas, 
because in the former the maternal structures are less perfectly dilated 
in consequence of the small size of the feet and thighs, and therefore the 
birth of the head is more apt to be delayed. 

Diagnosis. — Inasmuch as the long axis of the child corresponds 
with the long axis of the uterus in pelvic as in vertex presentations, 
there is nothing in the shape of the uterus to arouse suspicion as to the 
character of the case. Still, it is often sufficiently easy to recognize a 
pelvic presentation by abdominal examination if we have occasion to 
make one. The facility with which it may be done depends a good 
deal on the individual patient. If she be not very stout, and if the 
abdominal parietes be lax and non-resistant, we shall generally be able 
to feel the round head at the upper part of the uterus, much firmer and 
more defined in outline than the breech. The conclusion will be for- 
tified if we hear the foetal heart beating on a level with or above the 
umbilicus. The greater resistance on one side of the abdomen will also 
enable us to decide with tolerable accuracy to which side the back of 
the child is placed. Information thus acquired is, at the best, uncer- 
tain, and we can never be quite sure of the existence of a pelvic pres- 
entation until we can corroborate the diagnosis by vaginal examina- 
tion. 

[In view of the greater risk to the life of the foetus in a delivery 
by the breech over that by the vertex, it is advisable, when the posi- 
tion is determined while the membranes are still intact, to change the 
presentation from pelvic to cephalic by external bimanual manipula- 
tion. — Ed.] 

The first circumstance to excite suspicion on examination per raginam, 
even when the os is undilated, is the absence of the hard globular mass" 
felt through the lower segment of the uterus, so characteristic of vortex 
presentations. When the os is sufficiently open to allow the membranes 
to protrude, although the presenting part is too high up to be within 
reach, we may be struck with the peculiar shape of the bag of mem- 
branes, which, instead of being rounded, projects a considerable distance 
through the os, like the finger of a glove. This is a peculiarity met 
with in all mal})resentations alike, and is, indeed, nuich less distiuct in 
breech than in footling presentations, because in tiie former the mem- 
branes are more stretched, just as they are in vertex cases. M'hen the 
membranes rupture^, instead of the waters dribbling away by degives, 
they often esca[)e with a rush, in consequence of the }>elvic extremity 

20 



306 LABOB. 

not fillmg up the lower part of the uterus so accurately as the head, 
which acts as a sort of ball-valve and prevents the sudden and complete 
discharge of the waters. 

Often on first examining, even when the membranes are ruptured, 
the presentation is too high up to be made out accurately. All that we 
can be certain of is, that it is not the head ; and the case must be care- 
fully watched and examinations frequently repeated until the precise 
nature of the presentation can be established. If the breech present, 
the finger first impinges on a round, soft prominence, on depressing 
which a bony protuberance, the trochanter major, can be felt. On 
passing the finger upward it reaches a groove, beyond which a similar 
fleshy mass, the other buttock, can be felt. In this groove various 
characteristic points diagnostic of the presentation can be made out. 
Toward one end we can feel the movable tip of the coccyx, and above 
it the hard sacrum with its rough projecting prominences. These points, 
if accurately made out, are quite characteristic, and resemble nothing in 
any other presentation. In front there is the anus, in which it is some- 
times, but by no means always, possible to insert the tip of the finger. 
If this can be done, it is easy to distinguish it from the mouth, with 
which it might be confounded, by observing that the hard alveolar 
ridges are not contained within it. Still more in front we may find the 
genital organs, the scrotum in male children being often much swollen 
if the labor has been protracted. Thus it is often possible to recognize 
the sex of the child before birth. 

The breech might be mistaken for the face, especially if the latter be 
much swollen ; but this mistake can readily be avoided by feeling the 
spinous processes of the sacrum. 

The knee is recognized by its having two tuberosities with a depres- 
sion between them. It might be confounded with the heel, the elbow, 
or the shoulder. From the heel it is distinguished by having two 
tuberosities instead of one ; from the elbow, by the latter having one 
sharp tuberosity, with a depression on one side, instead of a central 
depression and two lateral prominences ; and from the slioulder, by the 
latter being more rounded, having only one prominence, running from 
w^hich the acromion and clavicle can be traced. 

The foot may be mistaken for the hand. This error will be avoided 
by remembering that all the toes are in the same line, and that the great 
toe cannot be brought into apj^osition with the others, as the thumb can 
with the fingers. The internal border of the foot is much thicker than 
the external, whereas the two borders of the hand are of the same thick- 
ness. ^Moreover, the foot is articulated at right angles to the leg, and 
cannot be brought into a line with it, as the hand can with the arm. 
Finally, the projection of the calcaneum is characteristic and resembles 
nothing in the hand. 

Mechanism. — As is the case in other presentations, obstetricians 
have very variously subdivided breech presentations with the effect of 
needlessly complicating the subject. The simplest division, and that 
Avhich will most readily impress itself on the memory of the student, is 
to describe the breech as presenting in four positions, analogous to those 
of the vertex, the sacrum being taken as representing the occiput, and 



PELVIC PRESENTATIONS. 307 

the positions being numbered according to the part of the pelvis to 
which it points. Thus we have — 

First y or left sacro-anterior (sacro-lseva anterior, s.l.a., correspond- 
ing to the first position of the vertex). The sacrum of the child points 
to the left foramen ovale of the mother. 

Second, or right sacro-anterior (sacro-dextra anterior, s.d.a., corre- 
sponding to the second vertex position). The sacrum of the child points 
to the right foramen ovale of the mother. 

Third, or right sacro-posterior (sacro-dextra posterior, s.d.p., cor- 
responding to the third vertex position). The sacrum of the child 
points to the right sacro-iliac synchondrosis of the mother. 

Fourth, or left sacro-j)osterior (sacro-lseva posterior, s. L. p., corre- 
sponding to the fourth vertex position). The sacrum of the child 
points to the left sacro-iliac synchondrosis of the mother. 

Of these, as with the corresponding vertex positions, the first 
(s.L.A.) and third (s.d.p.) are the most common, their comparative 
frequency no doubt depending on the same causes. The mechanical 
conditions to which the presenting part is subjected are also identical, 
but the alterations of position of the breech in its progress are by no 
means so uniform as those of the head, on account of its less perfect 
adaptation to the pelvic cavity. The mechanism of the delivery of the 
shoulders and head in breech presentations, moreover, is of much 
greater practical importance than that of the body in vertex presen- 
tations, inasmuch as the safety of the child depends on its speedy and 
satisfactory accomplishment. Bearing these facts in mind, it will 
suffice to describe briefly the phenomena of delivery in the first 
(s.L.A.) and third (s.d.p.) breech positions. 

Position of the Child at Brim. — In the first position (s. l.a.) 
(Fig. Ill) the sacrum of the child points to the left forameu ovale; 
its back is consequently placed to the left side of the uterns and 
anteriorly, and its abdomen looks to the right side of the uterus and 
posteriorly. The sulcus between the buttocks lies in the right oblique 
diameter of the pelvis, while the transverse diameter of the buttocks 
lies in the left oblique diameter, the left buttock being most easily 
within reach. As in vertex presentations, the hips of the child lie on 
the same level at the pelvic brim, although Naegele describes the left 
hip as placed lower than the right. 

As the pains act on the body of the child the breech is gradually 
forced through the pelvic cavity, retaining the same relations as at the 
brim, its progress being generally more slow than that of the head, 
until it reaches the lower pelvic strait, when the same mechanism whicli 
produces rotation of the occiput comes to operate uj)on it. The result 
is a rotation of the child's pelvis, so that its transverse diameter comes 
to lie ap})roximately in the antero-posteri(n- diameter of the outlet ; its 
antero-posterior diameter corresponds to the transverse diameter o\' the 
mother's pelvis, the left hip lies behind the pubes and the rioht toward 
the sacrum. The rotation, which is admitted by the mnjority of obstet- 
ricians, is altogether denipd by Naegele. There can be no doubt, how- 
ever, that it does generally take place, but by no means so constantly as the 
corresponding rottition of the vertex; and it is not unoonimon tor it to 



308 



LABOR. 



be entirely absent and for the hips to be born in the oblique diameter 
of the outlet. The body of the child is said frequently not to follow 



Fig. 111. 




First, or Left Sacro-anterior Position (s. l. a.) of the Breech. 

the movement imparted to the hips, so that there is more or less of a 
twist in the vertebral column. 

The left hip now becomes firmly fixed behind the pubes, and a move- 

FiG. 112. 




Passage of the Shoulders and Partial Rotation of the Thorax. 

ment of extension analogous to that of the head in vertex presentations 
takes place. The right or posterior hip revolves round the fixed one, 
gradually distends the perineum, and is expelled first, the left hip 
rapidly following. As soon as both hi])s are born the feet slip out, 
unless the legs are completely extended upon the child's abdomen. 
The shoulders soon follow, lying in the left oblique diameter of the 
pelvis (Fig. 112). The left shoulder rotates forward behind the pubes, 



PELVIC PRESENTATIONS. 



309 



where it becomes fixed, the right shoulder sweeping over the perineum 
and being born first. The arms of the child are generally found 
placed upon its thorax, and are born before the shoulders. Sometimes 
they are extended over the child's head, thus causing considerable delay 
and greatly increasing the risk to the child. It is now generally 
admitted that such extension is most apt to occur when traction has 
been made on the child's body with the view of hastening delivery, and 
that it is rarely met with when the expulsion of the body is left entirely 
to the normal powers. 

Delivery of the Head. — When the shoulders are expelled the head 
enters the pelvis in the opposite, or right oblique, diameter, the face look- 
ing to the right sacro-iliac synchondrosis. As the greater part of the 
child is now expelled, and as the head has entered the vagina, the uterus, 
having a comparatively small mass to contract upon, must obviously act 
at a mechanical disadvantage. Still, the pressure of the head on the 
vagina is a powerful inciter, the accessory muscles of parturition are 
brought into strong action, and there may be sufficient force to ensure 
expulsion of the head without artificial aid. On account of the great 
resistance to the descent of the occiput from its articulation with the 
spinal column, the pains have the effect of forcing down the anterior 
portion of the head, and this ensures the complete flexion of the chin 
upon the sternum (Fig. 113). This is a great advantage from a mechan- 

FiG. 113. 




Descent of the Head. 

ical point of view, as it causes the short occipito-mental diameter of the 
head to enter the pelvis in the axis of the uterus and the brim. If the 
head should be in a state of ])artial extension — as sometimes happens 
when the pelvis is usually roomy — the occipito-frontal diameter is 
placed in a similar relation to the brim — a position certainly less thvi>r- 
able to the easy birth of {\\q head. As the head descends it experiences 
a movement of rotation, {\\q occiput passing forward and to the rieht 
behind the pubic arch, the fac(^ turning backward into the hollow of the 
sacrum. The body of t.he child will be observed to follow this move- 
ment, so that its back is turned toward the mother's abdomen, its 
anterior surface to the perineum. The na[>e ot' the neck now becomes 



310 LABOR. 

firmly fixed under the arch of the piibes; the pains act chiefly on the 
anterior portion of the head and cause it to sweep over the perineum, 
the cliin being first born, then the mouth and forehead, and lastly the 
occiput. 

It is needless to describe the differences between the mechanism of 
the second (s. D. A.) and first (s. L. A.) positions, which the student, who 
has mastered the subject of vertex presentations, will readily under- 
stand. It is necessary, however, to say a few Avords as to sacro-poste- 
rior positions, choosing for that purpose the third (s. D. p.), which is the 
more common of the two. This is exactly the opposite of the first 
(s. L. A.) position. The sacrum of the child points to the right sacro-iliac 
synchondrosis ; its abdomen looks forward and to the left side of the 
mother. The transverse diameter of the child's pelvis lies in the left 
oblique diameter, the right hip being anterior. The birth of the body 
generally takes place exactly in the way that has been already described, 
the right hip being toward the pubes. 

As the head descends into the pelvis the occiput most usually rotates 
along its right side — the rotation haviug been often already partially 
effected when that of the hips had been made — until it comes to rest 
behind the pubes, the face passing backward along the left side of the 
pelvis into the hollow of the sacrum. This change corresponds exactly 
to the anterior rotation of the occiput in occipito-posterior positions, and 
is the natural and favorable termination. 

Sometimes further rotation does not take place, and the occiput then 
turns backward into the hollow of the sacrum. AVhat then generally 
occurs is, that the pains continue, for the reason already mentioned, to 
depress the chin and produce strong flexion of the face on the sternum, 
the occiput becoming fixed on the anterior border of the perineum. 
The pains continue to act chiefly on the anterior part of the head, the 
face is born first behind the pubes, the occiput only slipping over the 
perineum after the forehead has been expelled. 

The second mode of termination of such positions is mentioned in 
most works on the authority of one or two recorded cases, but, although 
mechanically possible, it is certainly an event of extreme rarity. The 
chin, instead of being flexed on the sternum,isgreatly extended, so that 
the face of the child looks upward toward the pelvic brim. The child 
then hitches over the upper edge of the pubes, and becomes fixed there, 
while the force of the uterine contractions is expended on the posterior 
part of the head, which descends through the pelvis, distending the 
perineum, and is born first, the face subsequently following. 

The mechanism of the delivery of the body and head in cases in 
which the feet originally present does not differ, in any important 
respect, from that which has been already described, and requires no 
separate notice. 

Treatment. — From what has been said of the natural mechanism, it 
is evident that one of the most fruitful causes of difficulty and compli- 
cation is undue interference on the part of the practitioner. It is no 
doubt tempting to use traction on the partially-born trunk in the hope 
of expediting delivery ; but when it is remembered that this is almost 
certain to produce extension of the arms above the head, and subse- 



PELVIC PRESENTATIONS. 311 

quently extension of the occiput on the spine, both of which seriously 
increase the difficulty of delivery, the necessity of leaving the case as 
much as possible to nature will be apparent. 

Having once, therefore, determined the existence of a pelvic presen- 
tation, nothing more should be done until the birth of the breech. The 
membranes should be even more carefully prevented from prematurely 
rupturing than in vertex presentations, since they serve to dilate the 
genital passages better than the presenting part. Hence they should 
be preserved intact, if possible, until they reach the floor of the pel- 
vis, instead of being punctured as soon as the os is fully dilated. The 
breech when born should be received and supported in the palm of 
the hand. 

When the body is expelled as far as the umbilicus, the dangers 
to the child commence ; for now the cord is apt to be pressed between 
the body of the child and the pelvic walls. To obviate this risk as 
much as possible, a loop of the cord should be pulled down, and 
carried to that part of the pelvis where there is most room, which 
will generally be opposite one or the other sacro-iliac synchondrosis. 
As long as the cord is freely pulsating we may be satisfied that the 
life of the child is not gravely imperilled, although delay is fraught 
with danger from other sources which have been already indicated. 
In most cases the arms now slip out ; but it may happen, even w^ith- 
out any fault on the part of the accoucheur, that they are extended 
above the head, and it is of great importance that we should be 
thoroughly acquainted with the best means of liberating them from 
their abnormal position. 

They must, of course, never be drawn directly downward, or the 
almost certain result would be fracture of the fragile bones. AVe 
should endeavor to make the arm sweep over the face and chest of 
the child, so that the natural movements of its joints should not be 
opposed. If the shoulders be within easy reach, the finger of the 
accoucheur should be slipped over that which is posterior — because 
there is* likely to be more space for this manoeuvre toward the sacrum 
— and gently carried downward toward the elbow^, whicli is drawn 
over the face, and then onward, so as to liberate the forearm. The 
same manoeuvre should then be applied to the opposite arm. It may be 
that the shoulders are not easily reached, and then they may be 
depressed by altering the position of the child's body. If this be 
carried well up to the mother's abdomen, the posterior shoulder will 
be brought lower down ; and by reversing this procedure and carry- 
ing the body back over the perineum the anterior shoulder may be 
similarly depressed. It is only very exceptionally, however, that 
these expedients are required. 

Birth of the Head. — The arms being extracted, some degroo of 
artificial assistance is at this time ahnost always requirtxl. If tliero 
be nnich delay, the child will ahnost certainly perish. Attempts have 
been made, in cases in which delivery of the head could not be rap- 
idly eflected, to establrsh pulmonary resjiiration by passing one or two 
fingers into the vagina, so as to press it back and admit air to the 
child's mouth, or by passing a catheter or tube into the mouth. 



312 LABOR. 

Xeither of these expedients is reliable, and we should rather seek to 
aid nature in completing the birth of the head as rapidly as possi- 
ble. The first thing to do, supposing the face to have rotated into 
the cavity of the sacrum, is to carry the body of the child well up 
tow^ard the pubes and abdomen of the mother without applying any 
traction, for fear of interfering with the all-important flexion of the 
chin on the sternum. If now the patient bear down strongly, the 
natural powers may be sufficient to complete delivery. If there be 
any delay, traction must be resorted to, and we must endeavor to 
apply it in such way as to ensure flexion. For this purpose, w^hile 
the body of the child is grasped by the left hand and drawn upward 
toward the mother's abdomen, the index and middle fingers of the 
right hand are placed on the back of the child's neck, so that their 
tips press on either side of the base of the occiput and push the head 
into a state of flexion. In most w^orks we are advised to pass the 
index and middle fingers of the left hand at the same time over the 
child's face, so as to depress the superior maxilla. Dr. Barnes insists 
that this is quite unnecessary, and that extraction in the manner 
indicated, by pressure on the occiput, is quite sufficient. Should it 
not prove so, flexion of the chin may be very effectually assisted by 
downward pressure on the forehead through the rectum. One or two 
fingers of the left hand can readily be inserted into the bowel, and the 
expulsion of the head is thus materially facilitated. 

By far the most powerful aid, however, in hastening delivery of the 
head, should delay occur, is pressure from above. This has been, 
strangely enough, almost altogether omitted by writers on the subject. 
It has been strongly recommended by Professor Penrose, and there 
can be no question of its utility. Indeed, as the uterus contracts tight- 
ly round the head uterine expression can be applied almost directly 
to the head itself, and without any fear of deranging its proper relation 
to the maternal passages. It is very seldom indeed that a judicious 
combination of traction on the part of the accoucheur, with firm pres- 
sure through the abdomen applied by an assistant, will fail in affecting 
delivery of the head before the delay has had time to prove injurious 
to the child. 

Application of the Forceps to the After-coming Head. — i\Iany 
accoucheurs — among others, Meigs and Rigby — advocate the applica- 
tion of the forceps when there is delay in the birth of the after-coming 
head. If the delay be due to want of expulsive force in a pelvis of 
normal size, manual extraction in the manner just described will be 
found to be sufficient in almost every case, and preferable, as being 
more rapid, easier of execution, and safer to the child. The forceps 
may be quite properly tried if other means have failed, especially if 
there be some disproportion between the size of the head and the 
pelvis. 

Difficulties in delivery may also occur in sacro-posterior positions. 
Up to the time of the birth of the head the labor usually progresses 
as readily as in sacro-anterior positions. If the forward rotation of 
the hips do not take place, much subsequent difficulty may be pre- 
vented by gently favoring it by traction applied to the breech during 



PELVIC PRESENTATIONS. 313 

the pains, the finger being passed for this purpose into the fold of the 
groin. 

It is after tlie birth of the shoulders that the absence of rotation is 
most likely to prove troublesome. It has been recommended that the 
body should then be grasped in the interval between the pains and 
twisted round so as to bring the occiput forward. It is by no means 
certain, however, that the head would follow the movement imparted 
to \hQ body, and there must be a serious danger of giving a fatal twist 
of the neck by such a manoeuvre. The better plan is to direct the face 
backward toward the cavity of the sacrum, by pressing on the anterior 
temple during the continuance of a pain. In this way the proper rota- 
tion will generally be eifected without much difficulty, and the case will 
terminate in the usual way. 

If rotation of the occiput forward do not occur, it is necessary for 
the practitioner to bear in mind the natural mechanism of delivery 
under such circumstances. In the majority of cases the proper plan is 
to favor flexion of the chin by upward pressure on the occiput, and to 
exert traction directly backward, remembering that the nape of the neck 
should be fixed against the anterior margin of the perineum. If this 
be not remembered, and traction be made in the axis of the pelvic out- 
let, the delivery of the head will be seriously impeded. In the rare 
cases in which the head becomes extended and the chin hitches on the 
upper margin of the pubes, traction directly forward and upward may 
be required to deliver the head ; but before resorting to it care should 
be taken to ascertain that backward extension of the head has really 
taken place. 

It remains for us to consider the measures which may be adopted in 
those troublesome cases in which the breech refuses to descend, and 
becomes impacted in the pelvic cavity either from uterine inertia or 
from disproportion between the breech and the pelvis. The peculiar 
shape of the presenting part unfortunately renders such cases very 
difficult to manage. 

Three measures have been chiefly employed : 1st, the forceps; 2d, 
bringing down one or both feet, so as to break up the presenting part 
and convert it into a footling case ; 3d, traction on the breech, either 
by the fingers, a blunt hook, or fillet passed over the groin. 

Forceps. — The forceps has generally been considered unsuited for 
breech cases in consequence of its construction to fit the fimal head, 
which renders it liable to slip when apj^lied to the breech. This objec- 
tion, probably to a great extent true with reference to most forceps, 
seems^ not to hold good when the axis-traction forceps of Tarnier or 
Simpson is used. Lusk strongly recommends it, and Harvey of Cal- 
cutta has published six consecutive cases in which he employed this 
method of delivery — in three with complete success. Truzzi,^ who 
has written strongly in favor of the forc(^ps in difficult breech cases, 
prefers it greatly to traction either by the fingers or the fillet when the 
breech is high in the ])elvis, and recommends that in order to sivure a 
strong hold the blades should be passed so that their extremities extend 
above tlie crests of the Ibotal ilia. 1 have only used it mvself in one 

^ Gaz. Med. ltd. Lomh., Auuusi. 1SS3. 



314 LABOR. 

or two cases, but iu these the results were extremely good, and delivery- 
was eiFected with a facility which surprised me; and I can see no objec- 
tion to a cautious trial of the instrument. [A better-fitting instrument 
is the special breech-forceps, Avith oval fenestrse, flat-edged blades, and 
long superimposed shanks, modelled to fit the sides of the breech over 
the trochanters and ilise. — Ed,] 

Bring-ing- Down a Foot. — Barnes insists on the superiority of the 
second plan ; and there can be no question that if a foot can be got 
down the accoucheur has a complete control over the progress of the 
labor which he can gain in no other way. If the breech be arrested 
at or near the brim, there Avill generally be no great difficulty in effect- 
ing the desired object. It Avill be necessary to give chloroform to the 
extent of complete anaesthesia, and to pass the hand over the child's 
abdomen in the same manner and with the same precautions as in per- 
forming podalic version until a foot is reached, which is seized and 
pulled down. If the feet be placed in the usual way close to the but- 
tocks, no great difficulty is likely to be experienced. If, however, the 
legs be extended on the abdomen, it will be necessary to introduce the 
hand and arm very deeply, even up to the fundus of the uterus — a 
procedure ^vhich is always difficult and which may be very hazardous. 
Nor do I think that the attempt to bring down the feet can be safe 
when the breech is low down and fixed in the pelvic cavity. A cer- 
tain amount of repression of the breech is possible, but it is evident 
that this cannot be safely attempted when the breech is at all low 
down. 

Traction on the Groin. — Under such circumstances traction is our 
only resource, and this is always difficult and often unsatisfactory. Of 
all contrivances for this purpose, none is better than the hand of the 
accoucheur. The index finger can generally be slipped over the groin 
without difficulty, and traction can be applied during the pains. Fail- 
ing this or when it proves insufficient, an attempt should be made to 
pass a fillet over the groins. A soft silk handkerchief or a skein of 
worsted answers best, but is by no means easy to apply. The simplest 
plan, and one which is far better than the expensive instruments con- 
trived for the purpose, is to take a stout piece of copper wire and bend 
it double into the form of a hook. The extremity of this can gener- 
ally be guided over the hips, and through its looped end the fillet is 
passed. The wire is now withdrawn, and carries the fillet over the 
groins. I have found this simple contrivance, which can be manu- 
factured in a few moments, very useful, and by means of such a fillet 
very considerable tractive force can be employed. The use of a soft 
fillet is in every way preferable to the blunt hook which is contained 
in most obstetric bags. A hard instrument of this kind is quite as 
difficult to apply, and any strong traction employed by it is almost 
certain to seriously injure the delicate foetal structures over which it is 
placed. As an auxiliary the employment of uterine expression should 
not be forgotten, since it may give material aid when the difficulty is only 
due to uterine inertia. After a difficult breech labor is completed the 
child should be carefully examined to see that the bones of the thighs 
and arms have not been injured. Fractures of the thigh are far from 



PRESENTATIONS OF THE FACE. 315 

uncommon in such cases, and the soft bones of the newly-born child 
will readily and rapidly unite if placed at once in proper splints. 

Embryotomy. — Failing all endeavors to deliver by these expedients, 
there is no resource left but to break up the presenting part by scissors 
or by craniotomy instruments ; but, fortunately, so extreme a measure 
is but rarely necessary. 



CHAPTER YI. 

PRESENTATIONS OF THE FACE. 

Presentations of the face are by no means rare, and, although in 
the great majority of cases they terminate satisfactorily by the unassisted 
powers of nature, yet every now and again they give rise to much dif- 
ficulty, and then they may be justly said to be amongst the most formi- 
dable of obstetric complications. It is therefore essential that the prac- 
titioner should thoroughly understand the natural history of this variety 
of presentation, with the view of enabling him to intervene with the best 
prospect of success. 

The older accoucheurs had very erroneous views as to the mechanism 
and treatment of these cases, most of them believing that delivery was 
impossible by the natural efforts, and that it was necessary to intervene 
by version in order to effect delivery. Smellie recognized the fact that 
spontaneous delivery is possible, and that the chin turns forward and 
under the pubes ; but it was not until long after his time, and chiefly 
after the appearance of Mme. La Chapel le's essay on the subject, that 
the fact that most cases could be naturally delivered was fully admitted 
and acted upon. 

Frequency. — The frequency of face presentation varies curiously in 
different countries. Thus, Collins found that in the Rotunda Hospital 
there was only 1 case in 497 labors, although Churchill gives 1 in 249 
as the average frequency in British practice, while in Germany this pros- 
entatiou is met with once in 1()9 labors. The only reasonable expla- 
nation of this remarkable dilference is that the dorsal decubitus, gener- 
ally followed abroad, favors the transformation of vertex presentations 
into those of the face. 

The mode in which this change is effecteil — for it can hardly Iv 
doubted that in the large majority of cases face presentation is due to a 
backward displacement of the occiput alUn* labor has actuallv coin- 
menced, but befon^ the head has engaginl in the brim — has boon made 
the subject of various explanations. 

It has generally boon supposoil that the ohango is induood b\ a hitoh- 



316 LABOR. 

ing of the occiput on the brim of the pelvis, so as to produce extension 
of the head and descent of the face, the occurrence being favored bv the 
oblique position of the uterus so frequently met ^vith in preguancv. 
Hecker^ attaches considerable importance to a peculiarity in the shape 
of the foetal head generally observed in face presentations, the cranium 
having the dolichocephalous form, prominent posteriorly Avith the occi- 
put projecting, which has the eifect of increasing the length of the pos- 
terior cranial lever arm and facilitating extension when circumstances 
favoring it are in action. Dr. Duncan^ thinks that uterine obliquity 
has much influence in the production of face presentation, but in a dif- 
ferent way to that above referred to. He points out that when obliquitv 
is very marked a curve in the genital passages is produced, the convex- 
ity of which is directed to the side toward which the uterus is deflected. 
When uterine contraction commences the foetus is propelled doAvnward, 
and the part corresponding to the concavity of the curve is acted on to 
the greatest advantage by the propelling force, and tends to descend. 
Should the occiput happen to lie in the convexity of the curve so 
formed, the tendency will be for the forehead to descend. In the 
majority of cases its descent will be prevented by the increased resistance 
it meets with in consequence of the greater length of the anterior cra- 
nial lever arm ; but if the uterine obliquity be extreme this may be 
counterbalanced, and -a face presentation ensues. The influence of this 
obliquity is corroborated by the observation of Baudelocqtie, that the 
occiput in face presentations almost invariably corresponds to the side of 
the uterine obliquity. A further corroboration is afforded by the fact 
that in face presentation the occiput is much more frequently directed to 
the right than to the left, while right lateral obliquity of the uterus is 
also much more common. 

These theories assume that face presentations are produced during 
labor. In a few cases they certainly exist before labor has commenced. 
It is possible, however, as we know that uterine contractions exist inde- 
pendently of actual labor, that similar causes may also be in operation, 
although less distinctly, before the commencement of labor. 

The diagnosis is often a matter of considerable difficulty at an early 
period of labor, before the os is fully dilated and the membranes rup- 
tured, and when the face has not entered the ]3elvic cavity. The finger 
then impinges on the rounded mass of the forehead, which may very 
readily be mistaken for the vertex. At this stage the diagnosis may be 
facilitated by abdominal palpation in the way suggested by Hecker. If 
the face is presenting at the brim, palpation will enable us to distinguish 
a hard, firm, and rounded body immediately above the pubes, which is 
the forehead and sinciput ; on the other side will be felt an indistinct, 
soft substance, corresponding to the thorax and neck. AVhen labor is 
advanced and the head has somewhat descended, or when the membranes 
are ruptured, we should be able to make out the nature of the presenta- 
tion with certainty. The diagnostic marks to be relied on are the edges 
of the orbits, the prominence of the nose, the nostrils (their orifices show- 
ing to which part of the pelvis the chin is turned), and the cavity of the 
mouth with the alveolar ridges. If these be made out satisfactorily, no 

^ TJeher die Schadel/onn bei Gesichtslagen. ^ Edin. Med. Journ., vol. xv. 



PRESENTATIONS OF THE FACE. 317 

mistake should occur. The most difficult cases are those in which the 
face has been a considerable time in the pelvis. Under such circum- 
stances the cheeks become greatly swollen and pressed together, so as to 
resemble the nates. The nose might then be mistaken for the genital 
organs, and the mouth for the anus. The orbits, however, and the alve- 
olar ridges resemble nothing in the breech, and should be sufficient to 
prevent error. Considerable care should be taken not to examine too 
frequently and roughly, otherwise serious injury to the delicate struc- 
tures of the face might be inflicted. AVhen once the presentation has 
been satisfactorily diagnosed, examinations should be made as seldom 
as possible, and only to assure ourselves that the case is progressing 
satisfactorily. 

Mechanism. — If we regard face presentations, as we are fully justi- 
fied in doing, as being generally produced by the extension of the occi- 
put in what were originally vertex presentations, we can readily under- 
stand that the position of the face in relation to the pelvis must 
correspond to that of the vertex. This is, in fact, what is found to be 
the case, the forehead occupying the position in which the occiput would 
have been placed had extension not occurred. 

The face, then, like the head, may be placed with its long diameter 
corresponding to almost any of the diameters of the brim, but most 
generally it lies either in the transverse diameter or between this and the 
oblique, while as it descends in the pelvis it more generally occupies one 
or other of the oblique diameters. It is con:imon in obstetric works to 
describe two principal varieties of face presentation — viz. the right and 
left mento-iliac, according as the chin is turned to one or other side of 
the pelvis. It is better, however, to classify the positions in accordance 
with the part of the pelvis to which the chin points. AVe may there- 
fore describe four positions of the face, each being analogous to one of 
the ordinary vertex presentations, of which it is the transformation. 

The Pour Positions generally Met with. — First position (mento- 
dextra posterior, M. d. p.). — The chin points to the right sacro-iliac syn- 
chondrosis, the forehead to the left foramen ovale, and the long diam- 
eter of the face lies in the right oblique diameter of the pelvis. This 
corresponds to the first position of the vertex, and, as in that, the back 
of the child lies to the left side of the mother. 

Second position (mento-lreva posterior, ]\r. L. p.). — The chin poims to 
the left sacro-iliac synchondrosis, the forehead to the right foramen 
ovale, and the long diameter of the face lies in the left oblique diameter 
of the pelvis. This is the conversion of the second vertex position. 

Third position (mento-l<Tva anterior, ^r. i.. A.). — The forehead (^Fig. 
114) points to the right sacro-iliac synchondrosis, the chin to the loft 
foramen ovale, and the long diamotc^r of the face lies in the right 
oblique diameter of the pelvis. This is the conversion ot' the third vor- 
tex position. 

Fourth position (mento-dextra anterior, m. \\ a.). — The ton^hoad 
points to the left sacro-iliac synchondrosis, the chin to the right torainon 
ovale, and the long diameter of the face lies in the left oblique diam- 
eter of the pelvis. This is the conversion of the fourth vortex position. 

The relative froquency of those presentations is not yet positively 



318 LABOR. 

ascertained. It is certain that there is not the preponderance of fii^t 
facial (m. d. p.) that tliere is of first vertex (s. L. A.) positions ; and this 
may, no doubt, be explained by the supposition that an unusual vertex 
position may of itself facilitate the transformation into a face presenta- 

FiG. 114. 




Third Position (m. l. a ) in Face Presentations. 

tion. Winckel concludes that, cceteris paribus, a face presentation is 
more readily produced when the back of the child lies to the right than 
"when it lies to the left side of the mother ; the reason for this being 
probably the frequency of right lateral obliquity of the uterus. AVe 
shall presently see that with very rare exceptions it is absolutely essen- 
tial that the chin should rotate forward under the pubes before delivery 
can be accomplished ; and therefore we may regard the third and fourth 
face positions, in which the chin from the first points anteriorly, as more 
favorable than the first and second. 

The mechanism of delivery in face is practically the same as in ver- 
tex presentations ; and we shall have no difficulty in understanding it 
if we bear in mind that in face cases the forehead takes the place of, and 
represents the occiput in, vertex presentations. For 'the purpose of 
description we will take the first position of the face. 

1. The first step consists in the extension of the head, which is 
effected by the uterine contractions as soon as the membranes are rup- 
tured. By this the occiput is still more completely pressed back on the 
nape of the neck, and the fronto-mental, rather than the mento-breg- 
matic, diameter is placed in relation to the pelvic brim. This corre- 
sponds to the stage of flexion in vertex presentations. 

The chin descends below tlie forehead from precisely the same cause 
as the occiput in vertex presentations. On account of the extended 
position of the head the presenting face is divided into portions of un- 



PRESENTATIONS OF THE FACE. 



319 



equal length in relation to the vertebral column, tliroogh which the 
force is applied, the longer lever arm being toward the forehead. The 
resistance is therefore greatest toward the forehead, which remains behind 
while the chin descends. 

2. Descent. — As the pains continue the head (the chin being still in 
advance) is propelled through the pelvis. It is generally said that the 
face cannot descend, like the occiput, down to the floor of the pelvis, 
its descent being limited by the length of the neck. There is here, 
however, an obvious misapprehension. The neck from the chin to the 
sternum, when the head is forcibly extended, measures from 3J to 4 
inches — a length that is more than sufficient to admit of the face descend- 
ing to the lower pelvic strait. As a matter of fact, the chin is frequently 
observed in mento-posterior positions to descend so far that it is appa- 
rently endeavoring to pass the perineum before rotation occurs. At the 
brim the two sides of the face are on a level, but as labor advances the 
right cheek descends somewhat, the caput succedaneum forms on the 
malar bone, and, if a secondary caput succedaneum form, on the cheek. 

3. Rotation is by far the most important point in the mechanism of 
face presentations, for unless it occurs delivery, Avith a full-sized head 
and an average pelvis, is practically impossible. There are, no doubt, 
exceptions to this rule which must be separately considered, but it is cer- 
tain that the absence of rotation is always a grave and formidable com- 

FiG. 115. 




Rotation Forward of Chin. 



plication of face presentation. Fortunately, it is only very rarely that 
this is not eflPected. The meclianical causes are precisely those which jn'o- 
duce rotation of the occiput forward in vertex presentations. As it is ac- 
complished, the chin passes under the arch of the ]nibes and the occiput 
rotates into the hollow of the sacrum (Fig. 115) ; and then commences — 



320 LABOR. 



4. Flexion, a movement which corresponds to extension in vertex 
cases. The chin passes as far as it can under the pubic arch, and there 
becomes fixed. The uterine force is now expended on the occiput, which 
revolves, as it were, on its transverse axis (Fig. 116), the under surface 



Fig. 116. 




Passage of the Head through the External Parts in Face Presentation. 

of the chin resting on the pubes as a fixed point. Tliis movement goes 
on until at last the face and occiput sweep over the distended peri- 
neum. 

5. External rotation is precisely similar to that which takes place 
in head presentations, and, like it, depends on the movements imparted 
to the shoulders. 

Such is the natural course of delivery in the vast majority of cases ; 
but in order fully to understand the subject it is necessary tostudytho.se 
rare cases in which the chin points backward and forward rotation does 
not occur. These may be taken to correspond to the occipito-posterior 
positions, in which the face is born looking to the pubes ; but, unlike 
them, it is only very exceptionally that delivery can be naturally com- 
pleted. The reason of this is obvious, for the occiput gets jammed 
behind the pubes, and there is no space for the fronto-mental diameter 
to pass the autero-posterior diameter of the outlet (Fig. 117). Cases 
are indeed recorded in Avhich delivery has been effected with the chin 
looking posteriori}" ; but there is every reason to believe that this can 
only happen w^hen the head is either unusually small or the pelvis un- 
usually large. In such cases the forehead is pressed down until a portion 
appears at the ostium vaginse, when it becomes firmly fixed behind the 
pube-s, and the chin after many efforts slips over the perineum. AVhen 
this is effected flexion occurs, and the occiput is expelled without diffi- 
culty. The forehead is probably always on a lower level than the 
chin. 



PRESENTATIONS OF THE FACE. 321 

Dr. Hicks ^ has published a paper in which he attempts to show that 
this termination of face presentations is not so rare as is generally sup- 
posed, and he gives a single instance in which he effected delivery with 
the forceps; but he practically admits that special conditions are neces- 
sary, such as the " antero-posterior diameter of the outlet particularly 

Fig. 117. 




Illustrating the Position of the Head when Forward Rotation of the Chin does not take place. 

ample ^' and a diminished size of the head. When delivery is effected 
it is probable, as Cazeaux has pointed out, that the face lies in the 
oblique diameter of the outlet, and that the chin depresses the soft 
structures at the side of the sacro-ischiatic notch, which yield to the ex- 
tent of a quarter of an inch or more, and thereby permit the passage of 
the occipito-mental diameter of the head. It must, however, be borne 
well in mind that spontaneous delivery in mento-posterior positions is 
the rare exception, and that, supposing rotation does not occur — and it 
often does so at the last moment — artificial aid in one form or another 
will be almost certainly required. 

Prognosis of Face Presentations. — As regards the mother, in the 
great majority of cases the prognosis is favorable, but the labor is apt to 
be prolonged, and she is therefore more exposed to the risks attending 
tedious delivery. As regards the child, the prognosis is much more 
unfavorable than in vertex presentations. Even when the anterior 
rotation of the chin takes place in the natural way, it is estimated that 
1 out of 10 children is stillborn, while if not tlie death of the child is 
almost certain. This increased infantile mortality is evidently due to 
the serious amount of pressure to which the child is sul)jected, and 
])robably de})ends in many cases on cerebral congestion productxl bv 
pressure on the jugular veins, as the neck lies in the ]H^lvic cavity. 
Even when the child is born alive the face is always greatlv swollen 
and disfigured. In soine cases the deformity produccii in thi< wav is 

^ Obstd. Trans., 18(.H>, vol. vii. p. 57. 
21 



322 LABOR. 

excessive, and the features are often scarcely recognizable. This disfig- 
uration passes away in a few days, Init the practitioner should be 
aware of the probabilit}^ of its occurrence, and should warn the 
friends, or they might be unnecessarily alarmed and possibly might 
lay the blame on him. 

Treatment. — After ^vhat has been said as to the mechanism of de- 
livery in face presentation, it is obvious that the proper course is to 
leave the case alone, in the expectation of the natural efforts being 
sufficient for complete delivery. Fortunately, in the large majoritv of 
cases this course is attended by a successful result. 

The older accoucheurs, as has been stated, thought active interference 
absolutely essential, and recommended either podalic version or the 
attempt to convert the case into a vertex presentation by inserting 
the hand and bringing down the occiput. The latter plan was re- 
commended by Baudelocque, and is even yet followed by some 
accoucheurs. Thus Dr. Hodge ^ advises it in all cases in which face 
presentation is detected at the brim ; but, although it might not have 
been attended with evil consec^uences in his experienced hands, it is 
certainly altogether unnecessary, and would infallil3ly lead to most 
serious results if generally adopted. It may, however, be allowable in 
certain cases in ^^-hich the face remains above the brim and refuses to 
descend into the pelvic cavity. Even then it is Cjuestionable whether 
podalic version should not be preferred, as being easier of performance, 
giving, when once effected, a much more complete control over delivery 
and being less painful to the mother. Version is certainly preferable 
to the application of the forceps, which is introduced with difficult}^ in 
so high a position of the face, and does not take a secure hold, provided 
the face has not emerged from the mouth of the uterus. If it has 
passed through the cervix, version could not be effected without serious 
risk of rupture of the uterus. 

Schatz^ has more recently suggested the rectification of face presenta- 
tions at an early stage, before the rupture of the membranes, by manip- 
ulation through the abdomen. He raises the foetal body by pressiu'e on 
the shoulder and breast through the abdominal wall by one hand, while 
the breech is raised and steadied by the other. By this means the 
occiput is elevated, and then the breech is pressed downward, when 
head flexion is produced by the resistance of the pelvic walls. Of 
this method I have had no practical experience, but it obviously 
requires an unusual amount of skill and practice in abdominal pal- 
pation. 

When once the face has descended into the pelvis, difficulties may 
arise from two chief causes — uterine inertia and non-rotation forward 
of the chin. 

The treatment of the former class must be based on precisely the 
same general principles as in dealing with protracted labor in vertex 
presentations. The forceps may be applied with advantage, bearing in 
mind the necessity of getting the chin under the pubes, and, when this 
has been effected, of directing the traction forwai'd, so as to make the 
occiput slowly and gradually distend and sweep over the perineum. 

^Sy.^tem of Obstetrics, p. 335. 2 j^.^/j^ y; Qy^,^ 1373^ B(J. y. S. 313. 



PRESENTATIONS OF THE FACE. 323 

The second class of difficult face cases is much more important, aud 
may try the resources of the accoucheur to the utmost. Our first 
endeavor must be, if possible, to secure the anterior rotation of the 
chin. For this purpose various manoeuvres are recommended. By 
some we are advised to introduce the finger cautiously into the mouth 
of the child and draw the chin forward during a pain ; by others, to 
pass the finger up behind the occiput and press it backward during the 
pain. Schroeder points out that the difficulty often depends on the fact 
of the head not being sufficiently extended, so that the chin is not on a 
lower level than the forehead, and that rotation is best promoted by 
pressing the forehead upward with the finger during a pain, so as to 
cause the chin to descend. Penrose^ believes that non-rotation is gener- 
ally caused by the want of a point d^appui below, on account of the face 
being unable to descend to the floor of the pelvis, and that if this is 
supplied rotation will take place. In such cases he applies the hand or 
the blade of the forceps so as to press on the jiosterior cheek. By this 
means the necessary point d^appid is given ; and he relates several inter- 
esting cases in which this simple manoeuvre was effectual in rapidly 
terminating a previously lengthy labor. Any or all of these plans may 
be tried. We must bear in mind in using them that rotation is often 
delayed until the face is quite at the lower pelvic strait, so that we need 
not too soon despair of its occurring. If, however, in spite of these 
manoeuvres it does not take place, what is to be done ? If the head has 
not passed through the mouth of the uterus, turning would be the sim- 
plest and most effectual plan. I have succeeded in delivering in this 
way when all attempts at producing rotation had failed ; but generally 
the face will be too decidedly engaged to render it possible. An 
attempt might be made to bring down the occiput by the vectis or by a 
fillet; but if the face be in the pelvic cavity, it is hardly possible for this 
plan to succeed. An endeavor may be made to produce rotation by the 
forceps, but it should be remembered that rotation of the fice mechani- 
cally in this way is very difficult, and much more likely to be attended 
with fatal consequences to the child than when it is effected by the nat- 
ural efforts. In using forceps for this purpose the second or pelvic 
curve is likely to }:)rove injurious, and a short straight instrument is to 
be preferred. If rotation be found to be impossible, an endeavor may 
be made to draw the face downward, so as to get the chin over the 
perineum and deliver in the mento-posterior position ; but unless the 
child be small or the pelvis very capacious the attempt is unlikely to 
succeed. Finally, if all these means fail there is no resource left but 
lessening ihQ, size of the head by craniotomy — a dernier ressort which, 
fortunately, is very rarely required^ but which is certainly preferable to 
long-continued and violent endeavors to deliver with the chin pointing 
backward. 

Brow Presentations. — It sometimes happens that the head is jxir- 
tially extended, so as to bring the os frontis into the brim oi' the jn^lvis 
and form what is described as a "brow presentation." Should the head 
descend in this manner the diiliculties, although not insuperable, are a}>t 
to be very great, froin the lact that the long cervioo-iVontal diameter of 

^ Amcr. Supplancnt to OlK<i. Journ., 187(5-77, vol, iv. p. 1, 



324 LABOR. 

tbe head is engao^ed in the peh-ic cavity. The diagnosis is not difficult, 
for the OS frontis -will be detected by its rounded surface, while the 
anterior fontanelle is within reach in one direction, the orbit and root of 
the nose in another. 

Fortnnately, in the large majority of cases the brow presentations are 
spontaneously converted into either vertex or face presentations accord- 
ing as flexion or extension of the head occurs; and these must be 
regarded as the desirable terminations and the ones to be favored. Fc»r 
this purpose upward pressure must be made on one or other extremitv* 
of the presenting part during a pain, so as to favor flexion or extension; 
or, if the parts be sufficiently dilated, an attempt may be made to pass 
the hand over the occiput and draw it down, thus performing cephalic 
version. The latter is the plan recommended l>y Hodge, who describes 
the operation as easy. Long, in an excellent paper on this subject, has 
given flgnres to show that correction of the malpresentation by manip- 
ulation has given better results than any other method of treatment.^ 
It is questionable, howe\'er, if a well-marked brow presentation be dis- 
tinctly made out while the head is still at the brim, whether podahc 
version would not be the easiest and best operation. If the forehead 
have descended too low for this, and if' the endeavor to cionvert it into 
either a face or vertex presentation fail, the iorceps will probably be 
required. In such cases the face generally turns toward the pubes, the 
superior maxilla becomes fixed behind the pubic arch, and the occiput 
sweeps over the perineum. Ver}- great difficulty is likely to be experi- 
enced, and if inversion into either a vertex or face presentation cannot 
be effected, craniot^jmy is not u/^likely to be required. 



CHAPTEE YII. 
DIFFICULT OCX^IPITOPOBTEEIOK POBITIONB. 

A FEW words may be said in this place as Uj the management of 
occipit^>-pfjsterior jx/sitions of the head, especially of thosc^ in which 
forward n/tation oi' the occiput doc:* not take place. It has already 
Ijeen jx/mt/^ out that in the large majority of these cases the occ;iput 
TiitaUi^ forward without any jjarticular difficulty, and the labor termi- 
nates in the usual way, with the occiput emerging under the arch of the 
pu}>>es. 

In a aertain nural>er of cases such rotation does not occur, and diffi- 
culty and delay are aj/t to foUow. The jiropjrtion of cases in which 
faf/ic-t/i-pubes terminations of cxxipit^>-po^terior positions ocr'ur has been 
variously estimated, and they ai*e certainly more common than most of 

' AntsrUMn JourrooJ of Ob^Arlca, ]8S0, vol. xviii. p. 897. 



DIFFICULT OCCIPITO-POSTERIOR POSITIONS. 325 

our textbooks lead us to expeet. Dr. Uvedale West/ Avho studied the 
subject with great care, found the labor ended in this way in 79 out of 
2585 births, all these deliveries being exceptionally difficult. 

Causes of Face-to-Pubes Delivery. — He believed that forward 
rotation of the head is prevented by the absence of flexion of the chin 
on the sternum, so that the long occipito-frontal (o.F.), instead of the 
short suboccipito-bregmatic (s.o.B.), diameter of the head is brought 
into contact with the pelvic diameter ; hence the occiput is no longer 
the low^est point, and is not subjected to the action of those causes which 
produce forward rotation. Dr. Macdonald, who has written a thought- 
ful paper on the subject,^ believes that the non-rotation forward of the 
occiput is chiefly due to the lai'ge size of the head, in consequence of 
which " the forehead gets so wedged into the pelvis anteriorly that its 
tendency to slacken and rotate forward does not come into play." Dr. 
West's explanation, which has an important bearing on the management 
of these cases, seems to explain most correctly the non-occurrence of 
the natural rotation. 

The important question for us to decide is, How can we best assist in 
the management of cases of this kind when difficulties arise and labor 
is seriously retarded ? 

Mode of Treatment of Such Cases. — Dr. West, insisting strongly 
on the necessity of complete flexion of the chin on the sternum, advises 
that this should be favored by upward pressure on the frontal bone, 
with the view of causing the chin to approach the sternum and the 
occiput to descend, and thus to come within the action of the agencies 
which favor rotation. Supposing the pains to be strong and the fouta- 
nelle to be readily within reach, we may in this way very possibly fiivor 
the descent of the occiput, and w'ithout injuring the mother or increasing 
the difficulties of the case in the event of the manoeuvre failing. The 
beneflcial effects of this simple expedient are sometimes very remarkable. 
In two cases in which I recently adopted it, labor, previously delayed 
for a length of time without any apparent progress, although the pains 
were strong and effective, was in each instance rapidly flnished almost 
immediately after the up^vard pressure was applied. The rotation of 
the face backward may at the same time be favortxl by pressure on the 
pubic side of the forehead during the pains. 

Others have advised that the descent of the occiput should be piw 
moted by downward traction, applied by the vectis or fillet. The latter 
is the plan specially advocated by Hodge ;^ and the fillet certainly finds 
one of its most useful applications in cases of this kind, as being simpler 
of application and prob;d)ly more effective than the vectis. 

Ah hough any of these methods may be adopted, a word o{ caution 
is necessary against })rolonged and over-active endeavors at pixxlucing 
flexion and rotation when these seem delayed. All who have Matchtxi 
such cases must have observed that rotation often occuis spontaneous- 
ly at a very advanced period of labor, long after the head has Ihvu 
pressed down for a considerable time to the very outlet o{ the pelvis, 
and when it seems to have been making fruitless endeavors to emergv, 

' (Vanial Pirscntixiions, p. 3o. ' luiin. Med. Jouni., vol. 1874-75, p. oirj. 

'^ Sih^tan of ObfUtrics, p. 30S. 



326 LABOR, 

so tliat a little patience will often be sufficient to overcome the 
difficulty. 

In the event of assistance being absolutely required there is no reason 
Avhy the forceps should not be nsed. The instrument is not more difficult 
to apply than under ordinary circumstances, nor, as a rule, is much more 
traction necessary. Dr. Macdouald, indeed, in the paper already alluded 
to maintains that in persistent occipito-posterior positions there is almost 
always a want of proportion between the head and the pelvis, and that 
therefore the forceps will be generally required ; and he prefers it to 
any artificial attempts at rectification. Some peculiarities in the mode of 
delivery are necessary to bear in niind. In most works it is taught that 
the operator should pay special attention to the rotation of the head, 
and should endeavor to impart this movement by turning the occiput 
forward during extraction. Thus, Tyler Smith says : " In delivery 
with the forceps in occipito-posterior presentations the head should be 
slowly rotated during the process of extraction so as to bring the vertex 
toward the pubic arch, and thus convert them into occipito-anterior 
presentations." The danger accompanying any forcible attempt at 
artificial rotation will, however, be evident on slight consideration. 
It is true that in many cases when simple traction is applied the 
occiput will of itself rotate forward, carrying the instrument with it. 
But that is a very different thing from forcibly twisting round the 
head with the blades of the forceps, without any assurance that the 
body of the child will follow the movement. It is impossible to con- 
ceive that such violent interference should not be attended with serious 
risk of injury to the neck of the child. If rotation do not occur, the 
fair inference is that the head is so placed as to render delivery with the 
face to the pubes the best termination, and no endeavor should be made 
to prevent it. This rule of leaving the rotation entirely to nature, and 
using traction only, has received the approval of Barnes and most 
modern authorities, and is the one which recommends itself as the 
most scientific and reasonable. 

There are cases in which the pelvic curve of the forceps is of doubt- 
ful utility. When applied in the usual way the convexity of the blades 
points backward. If rotation accompany extraction, the blades neces- 
sarily follow the movement of the head and their convex edges will 
turn forward. It certainly seems probable that such a movement 
would subject the maternal soft parts to considerable risk. I have, 
however, more than once seen such rotation of the instrument happen 
without any apparent bad result ; but the dangers are obvious. Hence 
it would be a wise precaution either to use a pair of straight forceps for 
this particular operation, or to remove the blades and leave the case to 
be terminated by the natural powers w^hen the head is at the lower strait 
and rotation seems about to occur. Prof. Richardson^ advises that 
when the forceps is applied in persistent occipito-posterior positions it 
should be introduced with the pelvic curve reversed. He claims for 
this method that the traction is chiefly exerted on the occiput, where it 
is most needed, which thereby descends and produces the necessary 
flexion of the chin on the sternum. The forceps is then removed, and, 

^Medical Communications of the Massachusetts Medical Society, 1885, vol. xiii. No. 4. 



DIFFICULT OCCIPITO-POSTERIOR POSITIOXS. 327 

if the pains are sufficient, rotation forward is sure to take place. Of 
this plan I have no personal experience. When there is no rotation 
more than usual care should be taken with the [)erineum, which is 
necessarily much stretched by the rounded occiput. Indeed, the risk 
to the perineum is very considerable, and even with the greatest care 
it may be impossible to avoid laceration. 

Bearing these precautions in mind, delivery with the forceps in 
occipito-posterior positions offers no special difficulties or dangers. 

[Version by the Vertex. — The following are the teachings of sev- 
eral eminent American obstetricians upon the management of occipito- 
posterior positions : 

1. ^^ In primitive oblique occipito-posterior positions of the head 
nature will almost without exception cause spontaneous rotation of the 
occiput to the symphysis pubis ; but to favor this movement the Ijag of 
waters should be preserved. '^ 

2. " Spontaneous rotation, as a rule, does not begin until the head 
meets with resistance from the floor of the pelvis : hence no effiDrt to 
force rotation should be made until nature has proved herself inade- 
quate.'' 

3. " Where rotation forward is prevented, it is probably due to the 
position of the occiput having been originally directly backward, and 
only becoming oblique after the descent of the head into the pelvis, the 
position of the child's body preventing the anterior movement of its 
occiput ; that is, the sixth position of Hodge has changed into a fourth 
or fifth, but will not without assistance become a first or second." 

4. " If, then, rotation is not spontaneous after the head reaches the 
floor of the pelvis, version by the vertex will not take place, except it 
be forced by the vectis or forceps." 

Use of the Hand in Occipito-posterior Positions. — The introduc- 
tion of the hand for the purpose of effecting version by the vortex was 
strongly advocated by the late Dr. John kS. Parry of Philadelphia, 
whose hand was very small and thin, and could be used to great advan- 
tage. Prof. Ottavio Morisani of Naples is said to use his with even 
greater success, because of its smaller size. Large hands should not be 
used in primipara?. By this manoeuvre I once brought an occiput luidor 
the pubic arch of a primipara in three pains, after she had labored for 
hours to deliver herself. — Ed.] 



328 LABOR. 



CHAPTER yill. 

PRESENTATIONS OF THE SHOULDER, ARM, OR TRUNK.— COMPLEX 
PRESENTATIONS.— PROLAPSE OF THE FUNIS. 

In the presentations already considered the long diameter of the foe- 
tns corresponded with that of the uterine cavity, and in all of them the 
birth of the child by the maternal efforts was the general and normal 
termination of labor. We have now to discuss those important cases in 
which the long diameter of the foetus and uterus do not correspond, but 
in which the long foetal diameter lies obliquely across the uterine cavity. 
In the large majority of these it is either the shoulder or some part of 
the upper extremity that presents; for it is an admitted fact that 
although other parts of the body, such as the back or abdomen, may in 
exceptional cases lie over the os at an early period of labor, yet as labor 
progresses such presentations are almost always converted into those of 
the upper extremity. 

For all practical purposes we may confine ourselves to a consideration 
of shoulder presentations, the further subdivision of these into elboic or 
Jiand presentations being no more necessary than the division of pelvic 
presentations into breech, knee, and footling cases, since the mechanism 
and management are identical whatever part of the upper extremity 
presents. 

There is this great distinction between the presentations we are now 
considering and those already treated of, that on account of the rela- 
tions of the foetus to the pelvis, delivery by the natural poAvers is impos- 
sible except under special and very unusual circumstances that can 
never be relied upon. Intervention on the part of the accoucheur is 
therefore absolutely essential, and the safety of both the mother and 
child depends upon the early detection of the abnormal position of the 
foetus ; for the necessary treatment, which is comparatively easy and 
safe before labor has been long in progress, becomes most difficult and 
hazardous if there have been much delay. 

Position of the Foetus. — Presentations of the upper extremity or 
trunk are often spoken of as " transverse presentations '' or " cross- 
births ;" but both of these terms are misleading, as they imply that the 
foetus is placed transversely in the uterine cavity or that it lies directly 
across the pelvic brim. As a matter of fact, this is never the case, for 
the child lies obliquely in the uterus — not indeed in its long axis, but 
in one intermediate between its long and transverse diameters. 

Two great divisions of shoulder presentations are recognized — the one 
in which the back of the child looks to the abdomen of the mother 
(Fig. 118), and the other in which the back of the child is turned 
toward the spine of the mother (Fig. 119). Each of these is subdivided 
into two subsidiary classes, according as the head of the child is placed 
in the right or left iliac fossa. Thus in dorso-anterior positions, if the 



PRESENTATIONS OF THE SHOULDER, ETC. 329 

head lie in the left iliac fossa (left scapula-anterior — scapula-lseva ante- 
rior, S.L.A.), the right shoulder of the child presents ; if in the right 

Fig. 118. 



Dorso-anterior Presentation of the Arm (s.l.a.). 



iliac fossa (right scapula-anterior — scapula-dextra anterior, s.d.a.), the 
left. So iu dorso-posterior positions, if the head lie in the left iliac 



Fig. 119. 




Porso-postorior I'vosontJitiim of (ho Arm (s.p.a.). 

fossa (left scapula-posterior — soapula-hvva posterior, s.t..p.\ the lott 
shoulder presents ; if in the right, the right (^right soapula-postorlor — 
scapula-dextra posterior-, s.d.p.).^ Of the two ohisjses the (hn^o-nnto- 

^ Left and rii>lit refer in this nonKMU'lnturo. as in all positions, to the left aiul rii^ht 
side of the mother, without rouard to that oi the child. 



330 LABOR. 

rior positions are more common, in the proportion, it is said, of two 
to one. 

The causes of shoulder presentation are not well known. Amongst 
those most commonly mentioned are prematurity of the foetus and excess 
of liquor amnii ; either of these, by increasing the mobility of the foetus 
in utero, would probably have considerable influence. The fact that it 
occurs much more frequently amongst premature births has long been 
recognized. Undue obliquity of the uterus has probably some influence, 
since the early pains might cause the presenting part to hitch against the 
pelvic brim and the shoulder to descend. An unusually low attach- 
ment of the placenta to the inferior segment of the uterine cavity has 
been mentioned as a predisposing cause. In consequence of this the 
head does not lie so readily in the lower uterine segment, and is apt to 
slip ujj into one of the iliac fossae. This is supposed to explain the fre- 
quency of arm presentations in cases of partial or complete placenta 
prsevia. Danyau and Wigand believe that shoulder presentations are 
favored by irregularity in the shape of the uterine cavity, especially a 
relative increase in its transverse diameter. This theory has been gen- 
erally discredited by writers, and it is certainly not susceptible of proof ; 
but it seems far from unlikely that some peculiarity of shape may exists 
not capable of recognition, but sufficient to influence the position of the 
foetus. How otherwise are we to explain those remarkable cases, many 
of which are recorded, in which similar malpositions occurred in many 
successive labors ? Thus, Joulin refers to a patient who had an arm 
presentation in three successive pregnancies, and to another who had a 
shoulder presentation in three out of four labors. Certainly, such con- 
stant recurrences of the same abnormality could only be explained on 
the hypothesis of some very persistent cause such as that referred to. 
Pinard^ states that shoulder presentations are seven times more common 
in multiparse than in primiparse, in consequence, as he believes, of the 
laxity of the abdominal walls in the former, which allows the uterus to 
fall forward, and thus prevents the head entering the pelvic brim 
in the latter weeks of pregnancy. It is probable that merely accidental 
causes have most influence in the production of shoulder presentations, 
such as falls or undue pressure exerted on the abdomen by badly-fitting 
or tight stays. Partially transverse positions during pregnancy are cer- 
tainly much more common than is generally believed, and may often be 
detected by abdominal palpation. The tendency is for such malpo- 
sitions to be righted either before labor sets in or in the early period of 
labor ; but it is quite easy to understand how any persistent pressure, 
applied in the manner indicated, may perpetuate a position Avhich other- 
wise would have been only temporary. 

Prognosis and Frequency. — According to Churchill's statistics, 
shoulder presentations occur about once in 260 cases; that is, only 
slightly less frequently than those of the face. The prognosis to both 
the mother and child is much more unfavorable, for he estimates that 
out of 235 cases, 1 in 9 of the mothers and lialf the children were 
lost. The prognosis in each individual case wdll, of course, vary much 
with the period of delivery at which the malposition is recognized. If 
1 Annal. cVHycj. Pub. et cle Med., Jan., 1879. 



PRESENTATIONS OF THE SHOULDER, ETC. 331 

detected early, interference is (?asy and the prognosis ought to be good; 
whereas there are few obstetric difBculties more trying than a case of 
shoulder presentation, in which the necessary treatment has been delayed 
until the presenting part has been tightly jammed into the cavity of the 
pelvis. 

Diagnosis. — Bearing this fact in mind, the paramount necessity of an 
accurate diagnosis will be apparent; and it is specially important that we 
should be able not only to detect that a shoulder or arm is presenting, 
but that we should, if possible, determine which it is and how the body 
and head of the child are placed. The existence of a shoulder presen- 
tation is not generally suspected until the first vaginal examination is 
made during labor. The practitioner will then be struck with the 
absence of the rounded mass of the foetal head, and, if the os be opened 
and the membranes protruding, by their elongated form, ^vhich is com- 
mon to this and to other malpresentations. If the presenting part be 
too high to reach, as is often the case at an early period of labor, an 
endeavor should at once be made to ascertain the foetal position by 
abdominal examination. This is the more important as it is much more 
easy to recognize presentations of the shoulder in this way than those of 
the breech or foot ; and at so early a period it is often not only possible, 
but comparatively easy, to alter the position of the foetus by abdominal 
manipulation alone, and thus avoid the necessity of the more serious 
form of version. The method of detecting a shoulder presentation by ex- 
amination of the abdomen has already been described (p. 127), and need 
not be repeated. The chief points to look for are — the altered shape 
of the uterus and two solid masses, the head and the breech, one in 
either iliac fossa. The facility with which these parts may be recog- 
nized varies much in different patients. In thin women with lax ab- 
dominal parietes they can be easily felt, while in very stout women it may 
be impossible. Failing this method, we must rely on vaginal examina- 
tions, although before the membranes are ruptured and when the pre- 
senting part is high in the pelvis it is not always ensy to gain accurate 
information in this way. The difficulty is increased by the paramount 
importance of retaining the membranes intact as long as possible. It 
should be remembered, therefore, that when a presentation of the 
su})erior extremity is suspected, the necessary examinations should only 
be made in the inter v^als between the pains when the membranes arc lax» 
and never when they are rendered tense by the uterine contractions. 

As either the shoulder, the elbow, or the hand may present, it will be 
best to desciribe the peculiarities of each separately, and the means of 
distinguishing to which side of the body the presenting part belong^;. 

1. The shoulder is recognized as a round, snun^th ]m>minence, at 
one point of which may often be felt the sharp etlge of the acromion. 
If thQ. finger can be })assed sufficiently high, it may be possible to feel 
the clavicle and the spuie of the scapula. A still more comploto exami- 
nation may enable us to detect the ribs and the intercostal spaces, which 
would be quite conclusive as to the nature of the presentation, simv 
there is nothing resembling them in any other part of the Ixxlv. At 
the side of the shoulder the hollow ol" {\w axilla mav gonerallv bo made 
out. 



332 LABOR. 

lu order to ascertain the position of the child we have to find out in 
Avhich iliac fossa the head lies. This may be done in two wavs : 1st, the 
head may be felt through the abdominal parietes by palj^ation ; and, 2d, 
since the axilla always points toward the feet, if it point to the left side 
the head must lie in the right iliac fossa ; if to the right, the head must 
be placed in the left iliac fossa. Agaiu, the spine of the scapula must 
correspond to the back of the child, the clavicle to its abdomen ; and, 
by feeling one or other we know ^vhether we have to do with a dorso- 
anterior or dorso-posterior position. If we cannot satisfactorily de- 
termine the position by these means, it is quite legitimate practice to 
bring down the arm carefully, provided the membranes are ruptured, 
so as to examine the hand, which will be easily recognized as right 
or left. This expedient will decide the point; but it is one which 
it is better to avoid if possible, for it not only slightly increases the 
difficulty of turning, although perhaps not very materially, but the 
arm might possibly be injured in the endeavor to bring it down. 

The only part of the body likely to be taken for the shoulder is 
the breech ; but in that its larger size, the groove in which the 
genital organs lie, the second prominence formed by the other but- 
tock, and the sacral spinous j)rocesses are sufficient to prevent a mis- 
take. 

2. The elbow is rarely felt at the os, and may be readily recognized 
by the sharp prominence of the olecranon, situated between two lesser 
prominences, the condyles. As the elbow always points toward the feet, 
the position of the foetus can be easily ascertained. 

3. The hand is easy to recognize, and can only be confounded with 
the foot. It can be distino^uished bv its borders beino; of the same 
thickness, by the fingers being wider apart and more readily separated 
froin each other than the toes, and above all by the mobility of the 
thumb, which can be carried across the palm and placed in apposition 
with each of the fingers. 

It is not difficult to tell which hand is presenting. If the hand be 
in the vagina or beyond the vulva, and within easy reach, we recognize 
which it is by laying hold of it as if we were about to shake hands. If 
the palm lie in the palm of the practitioner's hand, with the two thumbs 
in apposition, it is the right hand ; if the back of the hand, it is the 
left. Another simple way is for the practitioner to imagine his own 
hand placed in precisely the same position as that of the fcetus, and this 
will readily enable him to verifv tlie previous diagnosis. A simple rule 
tells us how the body of the child is placed, for, provided we are sure the 
hand is in a state of supination, the back of the hand points to the back 
of the child, the palm to its abdomen, the thumb to the head, and the 
little finger to the feet. 

Mechanism. — It is perhaps hardly projjer to talk of a mechanism of 
shoulder presentations, since if left unassisted they almost invariably 
lead to the gravest consequences. Still, Xature is not entirely at fault 
even here, and it is well to study the means she adopts to terminate 
these malpositions. 

Terminations of Shoulder Presentation. — There are two possible 
terminations of shoulder presentation. In one, known as ''spontaneous 



PRESENTATIONS OF THE SHOULDER, ETC. 333 

version/^ some other part of the foetus is substituted for that originally 
presenting; in the other, ^^spontaneous evolution," the faitus is expelled 
by being squeezed through the pelvis, without tlie originally presenting 
part being withdrawn. It cannot be too strongly impressed on the mind 
that neither of these can be relied on in practice. 

Spontaneous Version. — Spontaneous version may occasionally occur 
before or immediately after the rupture of the membranes, when the 
foetus is still readily movable within the cavity of the uterus. A few 
authenticated cases are recorded in which the same fortunate issue took 
place after the shoulder had been engaged in the pelvic brim for a con- 
siderable time, or even after prolapse of the arm ; but its probaVjility is 
necessarily much lessened under such circumstances. Either the head 
or the breech may be brought down to the os in place of the original 
presentation. 

The precise mechanism of spontaneous version or the favoring cir- 
cumstances are not sufficiently understood to justify any positive state- 
ment with regard to it. 

Cazeaux believed that it is produced by partial or irregular contrac- 
tion of the uterus, one side contracting energetically, while the other 
remains inert or only contracts to a slight degree. To illustrate how 
this may effect spontaneous version let us suppose that the child is lying 
with the head in the left iliac fossa. Then, if the left side of the uterus 
should contract more forcibly than the right, it would clearly tend to 
push the head and shoulder to the right side until the head came to 
present instead of the shoulder. A very interesting case is related by 
Geneuil,' in which he was present during spontaneous version, in the 
course of which the breech was substituted for the left shoulder more 
than four hours after the rupture of the membranes. In this case the 
uterus was so tightly contracted that version was impossible. He 
observed the side of the uterus opposite the head contracting ener- 
getically, the other remaining flaccid, and eventually the case ended 
without assistance, the breech presenting. The natural moulding 
action of the uterus, and the greater tendency of the long axis of the 
child to lie in that of the uterus, no doubt assist the transformation ; 
and much must depend on the mobility of the fcetus in any individual 
case. 

That such changes often take place in the latter weeks of pregnancy, 
and before labor has actually commenced, is quite certain, and they are 
probably much more frequent than is generally supposed. AVhcu sjum- 
taneous version docs occur it is of course a most favorable event, and 
the termination and prognosis of the labor are then the same as if the 
head or breech had originally presented. 

Spontaneous Evolution. — The mechanism of spontaneous evolution, 
since it Avas first clearly worked out by Douglas, has been so often and 
carefully described that we know })recisely how it occurs. Although 
every now and then a case is recorded in which a living child has been 
born by this means, such an event is of extreme rarity ; and there is no 
doubt of the accuracy of th,e general, opinion, that spontaneous evolution 
can only happen when ,the pelvis is muisually roomy and the child 

^ Ami. dc Ginurohuiir, 187G, vol. v. p. 46S. 



334 



LABOR. 



small, and that it almost necessarily involves the death of the foetus 
on account of the immense pressure to Avhicli it is subjected. 

Two varieties are described, in one of which the head is first born, 
in the other the breech ; in both the originally presenting arm remained 
prolapsed. The former is of extreme rarity, and is believed only to 
have happened with very premature children whose bodies w^ere small 
and flexible, and Avhen traction had been made on the presenting arm. 
Under such circumstances it can hardly be called a natural process, and 
we may confine our attention to the latter and more common variety. 

What takes place is as follows : The presenting arm and shoulder 
are tightly jammed down, as far as possible, by the uterine contractions, 
and the head becomes strongly flexed on the shoulder. As much of 



Fig. 120. 




Sponianeous Evolution. (After Chira., 
This drawing was made from a patient wtio died undelivered, the body being frozen and bisected. 

the body of the foetus as the pelvis will contain becomes engaged, and 
then a movement of rotation occurs which brings the body of the child 
nearly into the autero-posterior diameter of the pelvis (Fig. 120). The 
shoulder projects under the arch of the pubes, the head lying above the 
symphysis and the breech near the sacro-iliac synchondrosis. It is 
essential that the head should lie forward above the pubes, so that the 



PRESENTATIONS OF THE SHOULDER, ETC. 335 

length of tlie neck may permit the shonlder to project under the pubic 
arch without any y^vai of tlie head entering the pelvic cavity. Ilie 
shoulder and neck of the child now become fixed points round which 
the body of the child rotates, and the whole force of the uterine con- 
tractions is expended on the breech. The latter, with the body, there- 
fore becomes more and more depressed, until at last the side of the 
thorax reaches the vulva, and, followed by the breech and inferior 
extremities, is slowly pushed out. As soon as the limbs are born the 
head is easily expelled. 

The enormous pressure to which the body is subjected in this process 
can readily be understood. As regards the practical bearings of this 
termination of shoulder presentations, all that need be said is that if 
we should happen to meet with a case in which the shoulder and thorax 
were so strongly depressed that turning was impossible, and in which 
it seemed that nature was endeavoring to effect evolution, we should be 
justified in aiding the descent of the breech by traction on the groin 
before resorting to the difficult and hazardous operation of embryotomy 
or decapitation. 

Treatment. — It is unnecessary to describe specially the treatment of 
shoulder presentation, since it consists essentially in performing the 
operation of turning, which is fully described elsewhere. It is only 
needful here to insist on the advisability of performing the operation 
in the way whi(;h involves the least interference with the uterus. Hence 
if the nature of the case be detected before the membranes are ruptured, 
an endeavor should be made — and ought generally to succeed — to turn 
by external manipulation only. If we can succeed in bringing the 
breech or head over the os in this way, the case will be little more 
troublesome than an ordinary presentation of these parts. Failing in 
this, turning by combined external and internal manipulation should 
be attempted, and the introduction of the entire hand should be reserved 
for those more troublesome cases in which the waters have long drained 
away and in which both these methods are inapplicable. 

Should all these means fail, we must resort to the manipulation of 
the child by embryulcia or decapitation, probably the most difficult and 
dangerous of all obstetric operations. [The Ca}sarean operation has been 
performed in the United States in 14 cases where the fcrtns was impacted 
in a transverse position, with a saving of 10 women, or 71.3-7 per cent. 
In seven cases the arm protruded ; in three the pelvis was small : and 
in two it was deformed. In three women there were natural labors tu 
subsequent periods. The four deaths were produced as follows : Case 
3 was in labor ninety-six liours, three days under a midwife, antl died 
of exhaustion in seventeen hours. Case 7 was twenty-six lu>urs in 
labor, and had been under the care of a midwife, who had given ergot 
freely ; she was nnich })n)strated and died in twelve hoin*s. Case Ss 
would in all probability have recovered had she not risen tVom her 
bed on the third day to defend her mother against her husband, who 
iwwx^' home drunk. The fright, excitement, and exertion caused hei- 
death in a few hours. Case 13 was three days in lab(>r, and ergot was 
largely used ; forceps, version, and craniotomy were all tried. Death 
came on the tenth day from the bursting <\^ an abscess ot* the abdomi- 



336 LABOR. 

Dal wall into the peritoneal cavity, resulting in septic peritonitis. Case 
11 was operated upon in June, 1880 ; was up and at work in a month ; 
became pregnant in two and a half more, and bore a child naturally in 
twelve and a half months after the operation. The uterine wound was 
closed ^^dth two silver-wire sutures. 

This operation certainly promises well in cases of impaction with an 
arm protruding where there has been no deforming pelvic disease. 
With the new conservative method such cases should be saved in large 
proportion in the United States. Will embryulcia or decapitation be 
likely to succeed as well in this country? — Ed.] 

Complex Presentations. — There are various so-called comj^Iex jrres- 
entations in which more than one part of the foetal body presents. 
Thus we may have a hand or a foot presenting with the head or a foot 
and hand presenting simultaneously. The former do not necessarily 
give rise to any serious difficulty, for there is generally sufficient room 
for the head to pass. Indeed, it is unlikely that either the hand or foot 
should enter the pelvic brim with the head, unless the head was unusu- 
ally small or the pelvis more than ordinarily capacious. As regards 
treatment, it is no doubt advisable to make an attempt to replace the 
hand or foot by pushing it gently above the head in the intervals 
between the pains, and to maintain it there until the head be fully 
engaged in the pelvic cavity. The engagement of the head can be 
hastened by abdominal pressure, which will be of great value. Fail- 
ing this, all we can do is to place the presenting member at the part 
of the pelvis where it will least impede the labor and be the least 
subjected to pressure ; and that will generally be opposite the temple 
of the child. As it must obstruct the passage of the head to a certain 
extent, the application of the forceps may be necessary. When the feet 
and hands present at the same time, in addition to the confusing nature 
of the presentation from so many ]3arts being felt together, there is the 
risk of the hands coming down and converting the case into one of arm 
presentation. It is the obvious duty of the accoucheur to prevent this 
l3y ensuring the descent of the feet, and traction should be made on them 
either with the fingers or with a fillet, until their descent and the ascent 
of the hands are assured. 

Dorsal Displacement of the Arm. — In connection with tliis subject 
may be mentioned the curious dorsal displacement of the arm first 
described by Sir James Simpson,^ in which the forearm of the child 
becomes thrown across and behind the neck. The result is the forma- 
tion of a ridge or bar which prevents the descent of the head into the 
pelvis by hitching against the brim (Fig. 121). The difficulty of diag- 
nosis is very great, for the cause of obstruction is too high up to be felt. 
But if we meet with a case in which the pelvis is roomy and the pains 
strong, and yet the head does not descend after an adequate time, a full 
exploration of the cause is essential. For this purpose we would nat- 
urally put the patient under chloroform and pass the hand sufficiently 
high.^ We might then feel the arm in its abnormal position. That 
was what took place in a case under my own care in which I failed to 
get the head through the brim with the forceps, and eventually deliv- 
1 Selected Obstet. Works, vol. i. 



PRESENTATIONS OE THE SHOULDER, ETC. 



337 



ered by turning. The same course was adopted by my friend Mr. Jar- 
dine Murray in a similar case.^ Simpson advises that the arm should 
be brought down so as to convert the case into an ordinary hand-and- 
head presentation. This, if the arm be above the brim, must always 
be difficult, and I believe the simpler and more effective plan is podalic 
version. A similar displacement may cause some difficulty in breech 
presentations and after turning (Fig. 122). Delay here is easier of 



Fig. 121. 



Fig 





Dorsal Displacement of the Arm, 



Dorsal Displacement of the Arm in Footling Presen- 
tations. (After Barnes.) 



diagnosis, since the obstacle to the expulsion will at once lead to careful 
examination. By carrying the body of the child well backward so as 
to enable the finger to pass behind the symphysis pubis and over the 
shoulder, it will generally be easy to liberate the arm. 

Prolapse of the Umbilical Cord. — It occasionally happens that the 
umbilical cord falls down past the presenting part (Fig. r23\, and is apt 
to be pressed between it and the walls of the pelvis. The consequence 
is that the foetal circulation is seriously interfered with, and the death 
of the child from asphyxia is a common result. Hence prolapse of the 
funis is a very serious complication of labor in so far a^ the child 
is concerned. 

Frequency. — Fortunately, it is not a very frequent occurrona\ 
Churchill calculates that out of over 105,000 deliveries it was mot with 



^ Mai. Times ami Oa:e((t\ 18(>1. 



22 



338 



LABOR. 



ODce in 240 cases, and Scanzoni once in 254. Its frequency varies much 
under different circumstances and in different places. We find from 
Churchill's figures a remarkable difference in the proportional number 
of cases observed in France, England, and Germany — viz. 1 in 446J, 
1 in 207|, and 1 in 156, respectively. Great as is the proportion refer- 



FiG. 123. 




Prolapse of the Umbilical Cord. 

red to Germany in these figures, it has been found to be exceeded in 
special districts. Thus, Engelman records 1 case out of 94 labors in the 
lying-in hospital at Berlin, and Michaelis 1 in 90 in that of Kiel. 
These remarkable differences are at first sight not easy to account for. 
Dr. Simpson suggests, with considerable show of probability, that the 
difference in frequency in England, France, and Germany may depend 
on the varying positions in Avhich lying-in women are placed during 
labor in each country. In France, where, although the patient is laid 
on her back, the pelvis is kept elevated, the complication occurs least 
frequently ; in England, w^here she lies on her side, more often ; and in 
Germany, where she is placed on her back Avith her shoulders raised, 
most often. The special frequency of prolapsed funis in certain dis- 
tricts, as in Kiel, is supposed by Engelman ^ to depend on the preva- 
lence of rickets, and consequently of deformed pelvis, which we shall 
presently see is probably one of the most frequent and important causes 
of the accident, 

Prog-nosis. — With regard to the danger attending prolapsed funis, 
as far as the mother is concerned it may be said to be altogether unim- 
portant, but the universal experience of obstetricians points to the great 
risk to w^hich the child is subjected. Scanzoni calculates that 45 per 
cent, only of the children were saved ; Churchill estimated the number 
at 47 per cent. ; thus, under the most favorable circumstances this com- 

^Amer. Journ. of Obst., 1873-74, vol. vi. pp. 409, 540. 



PRESENTATIONS OF THE SHOULDER, ETC. 339 

plication leads to the death of more than half the children. Engelman 
found that out. of 202 vertex presentations only 36 per cent, of the 
children survived. The mortality was not nearly so great in other 
presentations ; Q^ per cent, of the cases in which the child presented 
with the feet were saved, and 50 per cent, in original shoulder presen- 
tations. The reason of this remarkable difference is doubtless that in 
vertex presentations the head fits the pelvis much more com])letely and 
subjects the cord to much greater pressure ; while in other presentations 
the pelvis is less completely filled, and the interference with the circu- 
lation in the cord is not so great. Besides, in the latter case the com- 
plication is detected early and the necessary treatment sooner adopted. 

The foetal mortality is considerably greater in first labors — a result to 
be expected on account of the greater resistance of the soft parts and 
the consequent prolongation of the labor. 

The causes of prolapse of the funis are any circumstances which 
prevent the presenting part accurately fitting the pelvic brim. Hence 
it is much more frequent in face, breech, or shoulder than in vertex 
presentations, and is relatively more common in footling and shoulder 
presentations than in any other. Amongst occasional accidental predis- 
posing causes may be mentioned early rupture of the membranes, 
especially if the amount of liquor amnii be excessive, as the sudden 
escape of the fluid washes down the cord ; undue length of the cord 
itself; or an unusually low placental attachment. Engelman attaches 
great importance to slight contraction of the pelvis, and states that in 
the Berlin lying-in hospital, where accurate measurements of the pelvis 
were taken in all cases, it was almost invariably found to exist. The 
explanation is evident, since one of the first results of pelvic contrac- 
tion is to prevent the ready engagement of the presenting part in the 
pelvic brim. 

The diagnosis of cord presentation is generally devoid of diffieultv; 
but if the membranes are still unruptured, it may not always be quite 
easy to determine the precise nature of the soft structures felt through 
them, as they recede from the touch. If the pulsations of the cord can 
be felt through the membranes, all difliculty is removed. After the mem- 
branes are ruptured there is nothing for which it can well be mistaken. 

The important point to determine in such a case is ^^•hether the cord 
be pulsating or not; for if pulsations have entirely ceased the inference 
is that the child is dead, and the case may then be left to nature with- 
out further interference. It is of importance, however, to be carefid, 
for if the examination be made during a pain the circulation mioht be 
only temporarily arrested. The examination, therefore, should be made 
during an interval, and a loop of the cord }>ulled down, if nocessarv, to 
make ourselves absolutely certain on this point. 

The amount of the i)rolapse varies much. Sometimes only a knuckle 
of the cord, so small as to escape observation, is engaged between the 
pelvis and presenting })art. lender such circumstances the child mav 
be sacrificed without any suspicion i}^ danger having arisen. More 
often the amount prolapsed is considerabU^ — sometimes so as to lie in the 
vagina in a long looj), or even to protrude altogether bevond the vidva. 

In the treatment the great indication is to i^vvent the coi\l fivni 



340 



LABOR. 



being unduly pressed on^ and all our endeavors must have this object 
in view. If the presentation be detected before the full dilatation 
of the cervix, and when the membranes are unruptured, we must try 
to keep the cord out of the way; to preserve the membranes intact as 
long as possible, since the cord is tolerably protected as long as it is sur- 
rounded by the liquor amnii ; and to secure the complete dilatation of 
the OS, so that the presenting part may engage rapidly and completely. 

Much may be done at this time by the postural treatment, which we 
owe chiefly to the ingenuity of Dr. T. Gaillard Thomas of iSTew York, 
whose writings familiarized the profession with it, although it appears 
that a somewhat similar plan had been occasionally adopted previously. 
Dr. Thomas' method is based on the principle of causing the cord to 
slip back into the uterine cavity by its own weight. For this purpose 
the patient is placed on her hands and knees, with the hips elevated and 
the shoulders resting on a lower level (Fig. 124). The cervix is then 

Fig. 124. 




Postural Treatment of Prolapse of the Cord. 

no longer the most dependent portion of the uterus, and the anterior 
wall of the uterus forms an inclined plane down which the cord slips. 
The success of this manoeuvre is sometimes very great, but by no means 
always so. It is most likely to succeed when the membranes are un- 
ruptured. If, when adopted, the cord slip aw^ay and the os be suffi- 
ciently dilated, the membranes may be ruptured, and engagement of the 
head produced by properly applied uterine pressure. Sometimes the 
position is so irksome that it is impossible to resort to it. Postural 
treatment is not even then altogether impossible, for by placing the 
patient on the side opposite to that of the prolapse, so as to relieve 
the cord as much as possible from pressure, and at the same time 
elevating the hips by a pillow, it may slip back. Even after the 
membranes are ruptured postural treatment in one form or another 
may succeed ; and, as it is simple and harmless, it should certainly 
be always tried. Attempts at reposition by one or other of the 
methods described below may also occasionally be facilitated by try- 
ing them when the patient is placed in the knee-shoulder position. 
Failing by postural treatment or in combination with it, it is quite 



PRESENTATIONS OF THE SHOULDER, ETC. 



341 



legitimate to make an attempt to place the cord beyond tlie reach of 
dangerous pressure by other methods. Unfortunately^ reposition is too 
often disappointing, difficult to effect, and very frequently, even when 
apparently successful, shortly followed by. a fresh descent of the cord. 
Provided the os be fully dilated and the presenting head engaged in the 
pelvis (for reposition may be said to be hopeless when any other part 
presents), perhaps the best way is to attempt it by the hand alone. 
Probably the simplest and most effectual method is that recommended 
by McClintock and Hardy, who advise that the patient should lie 
on the opposite side to the prolapsed cord, which should then be 
drawn toward the pubes as being the shallowest part of the pelvis. 
Two or three fingers may then be used to push the cord past the 
head and as high as they can reach. They must be kept in the 
pelvis until a pain comes on, and then very gently withdrawn, in the 
hope that the cord may not again prolapse. During the pain ex- 
ternal pressure may very properly be applied to favor descent of the 
head. This manoeuvre may be repeated during several successive 
pains, and may eventually succeed. The attempt to hook the cord 
over the foetal limbs or to place it in the hollow of the neck, recom- 
mended in many works, involves so deep an introduction of the hand 
that it is obviously impracticable. 

Various complex instruments have been invented 
to aid reposition (Fig. 125), but even if we possessed 
them they are not likely to be at hand when the 
emergency arises. A simple instrument may be 
improvised out of an ordinary male elastic catheter 
by passing the two ends of a piece of string through 
it, so as to leave a loop emerging from the eye of 
the catheter. This is passed through the loop of 
prolapsed cord, and then fixed in the eye of the 
catheter by means of the stilette. The cord is then 
pushed up into the uterine cavity by the catheter, and 
liberated by withdrawing the stilette. Another sim- 
ple instrument may be made by cutting a hole in a 
piece of whalebone. A piece of tape is then passed 
through the loop of the cord and the ends threaded 
through the eye cut in the whalebone. By tighten- 
ing the tape the whalebone is held in close ap})osi- 
tion to the cord, and the whole is passed as high 
as possible into the uterine cavity, 
easily be liberated by pulling one 
ferred, the cord can be tied to 
is left in utevo until the 
need be said as to the 



Fig. 125. 



tape 
If 



can 
pre- 



The 

end 

the whalebone, 

child is born. 

various other 



which 

Nothing 

methods adopted for keeping up the I'on 

the insertion of pieces of sponge or tying tli 

in a bag of soft leather, since they are genera 

mitted to be quite usqless. 

It only too often ha})pens that all endeavoi*s at 
reposition fail. Tlie subsequent treatment nuist thou 



uich as 

le (.HMxl 

ad- 




Brauu's Apimratns for 
Replacing the Coni. 



hou bo uiiidod bv the 



342 LABOR. 

circumstances of the case. If the pelvis be roomy and the pains strongs 
especially in a multipara^ we may often deem it advisable to leave the 
case to nature, in the hope that the head may be pushed through before 
pressure on the cord has had time to prove fatal to the child. Under 
such circumstances the patient should be urged to bear down, and the 
descent of the head promoted by uterine pressure, so as to get the 
second stage completed as soon as possible. If the head be within easy 
re^ch, the application of the forceps is quite justifiable, since delay must 
necessarily involve the death of the child. During this time the cord 
should be placed, if possible, opposite one or other sacro-iliac synchon- 
drosis, according to the position of the head, as the part of the pelvis 
where there is most room and where the pressure would consequently be 
least prejudicial. If we have to do with a case in which the head has 
not descended into the pelvis, and postural treatment and reposition have 
both failed, provided the os be fully dilated and other circumstances be 
favorable, turning would undoubtedly offer the best chance to the child. 
This treatment is strongly advocated by Engelman, Avho found that 70 
per cent, of the children delivered in this way were saved. There can 
be no question that, so far as the interests of the child are concerned, it 
is, under the circumstances indicated, by far the best expedient. Turn- 
ing, however, is by no means always devoid of a certain risk to the 
mother, and the performance of the operation in any particular case 
must be left to the judgment of the practitioner. A fully-dilated os 
with membranes unruptured, so that version could be performed by the 
combined method without the introduction of the hand into the uterus, 
would be unquestionably the most favorable state. If it be not deemed 
proper to resort to it, all that can be done is to endeavor to save the cord 
from pressure as much as possible by one or other of the methods already 
mentioned. 



CHAPTER IX. 
PKOLONGED AND PKECIPITATE LABOKS. 

Among the difficulties connected with parturition there are none of 
more frequent occurrence, and none requiring more thorough knowledge 
of the physiology and pathology of labor, than those arising from defi- 
cient or irregular action of the expulsive powers. The importance of 
studying this class of labors will be seen when we consider the numerous 
and very diverse causes which produce them. 

Evil Effects of Prolonged Labor. — That the mere prolongation of 
labor is in itself a serious thing is becoming daily more and more an 
acknowledged axiom of midAvifery practice ; and that this is so is evi- 
dent Avhen we contrast the statistical returns of such institutions as the 



PROLONGED AND PRECIPITATE LABORS. 343 

Rotunda Lying-in Hospital of late years with those wliich were pub- 
lished some twenty or thirty years ago. It may be fairly assumed that 
the practice of the distinguished heads of that well-known school rep- 
resents the most advanced and scientific opinion of the day. When we 
find that less than thirty years ago the forceps was not used more than 
once in 310 labors, while, according to the report for 1873, the late 
master applied it once in 8 labors, it is apparent hgw great is the 
change wliich has taken place. 

Causes. — Labor may be prolonged from an immense number of 
causes, the principal of which will require separate study. Some depend 
simply on defective or irregular action of the uterus ; others act by 
opposing the expulsion of the child, as, for example, undue rigidity of 
the parturient passages, tumors, bony deformity, and the like. What- 
ever the source of delay, a train of formidable symptoms is developed 
which are fraught with peril both to the mother and the child. As 
regards the mother, they vary much in degree and in the rapidity with 
which they become established. In many cases, in which the action of 
the uterus is slight, it may be long before serious results follow ; while 
in others, in which a strongly-acting organ is exhausting itself in futile 
endeavors to overcome an obstacle the worst signs of protraction may 
come on with comparative rapidity. 

The stag-e of labor in -which delay occurs has a marked effect in 
the production of untoward symptoms. It is a well-established fact 
that prolongation is of comparatively small consequence to either the 
mother or child in the first stage, when the membranes are still intact 
and when the soft parts of the mother, as well as the body of the child, 
are protected by the liquor amnii from injurious pressure ; whereas 
if the membranes have ruptured prolongation becomes of the utmost 
importance to both as soon as the head has entered the pelvis, when the 
uterus is strongly excited by reflex stimulation, when the maternal soft 
parts are exposed to continuous pressure, and when the tightly con- 
tracted uterus presses firmly on the foetus and obstructs the placental 
circulation. It is in reference to the latter class of cases that the change 
of practice, already alluded to, has taken place, with the utmost bene- 
ficial results both to mother and child. 

It must not be assumed, however, that prolongation of labor is never 
of any consequence until the second stage has connnenced. The fallacy 
of such an opinion was long ago shown by Simpson, who proved in the 
most conclusive way that both the maternal and fcrtal mortality were 
greatly increased in proportion to the entire length of the labor ; and all 
practical accoucheurs are familiar with cases in which symptoms o'i 
gravity have arisen before the first stage is concluded. Still, relatively 
speaking, the opinion indicated is undoubtedly correct. 

In the present chapter we have to do only with those causes of delay 
connected with the expulsive powers. Inasnuich, however, as the inju- 
rious effects of protraction are similar in kind, whatever be the cause, it 
will save needless repetition if we consider, once for all, the tniiu o^ 
symptoms that arise \yhenever labor is unduly prolongcni. 

Delay in the First Stage is Rarely Serious. — As long as the delay 
is in the first stage only, with rare exceptions no symptoms of real grav- 



344 LABOR. 

ity arise for a length of time, it may be even for days. There is often, 
however, a partial cessation of the pains, which in consequence of tem- 
porary exhaustion of nervous force may even entirely disappear for 
many consecutive hours. • Under such circumstances, after a period of 
rest either natural or produced by suitable sedatives, they recur with 
renewed vigor. 

Symptoms of Protraction in the Second Stag-e. — A similar tem- 
porary cessation of the pains may often be observed after the head has 
passed through the os uteri, to be also followed by renewed vigorous 
action after rest. But now any such irregularity must be much more 
anxiously watched. In the majority of cases any marked alteration in 
the force and frequency of the pains at this period indicates a much 
more serious form of delay, which in no long time is accompanied by 
grave general symptoms. The pulse begins to rise, the skin to become 
hot and dry, the patient to be restless and irritable. The longer the 
delay and the more violent the efforts of the uterus to overcome the 
obstacle, the more serious does the state of the patient become. The 
tongue is loaded with fur, and in the w^orse cases dry and black ; nausea 
and vomiting often become marked ; the vagina feels hot and dry, the 
ordinary abundant mucous secretion being absent ; in severe cases it may 
be much swollen, and if the presenting part be firmly impacted a slough 
may even form. Should the patient still remain undelivered, all these 
symptoms become greatly intensified : the vomiting is incessant, the 
pulse is rapid and almost imperceptible, low^ muttering delirium super- 
venes, and the patient eventually dies with all the worst indications of 
profound irritation and exhaustion. 

So formidable a train of symptoms, or even the slighter degrees of 
them, should never occur in the practice of the skilled obstetrician ; and 
it is precisely because a more scientific knowledge of the process of par- 
turition has taught the lesson that under such circumstances prevention 
is better than cure, that earlier interference has become so much more 
the rule. 

Those w^ho taught that nothing should be done until nature had had 
every possible chance of effecting delivery, and w^ho, therefore, allowed 
their patients to drag on in many weary hours of labor at the expense 
of great exhaustion to themselves and imminent risk to their offspring, 
made much capital out of the time-honored maxim that ^^ meddlesome 
midwnfery is bad.'* AVhen this proverb is applied to restrain the rash 
interference of the ignorant, it is of undeniable value ; but w^hen it is 
quoted to prevent the scientific action of the experienced, who know 
precisely when and w^hy to interfere, and w^ho have acquired the 
indispensable mechanical skill, it is sadly misapplied. 

State of the Uterus in Protracted Labor. — The nature of the 
pains and the state of the uterus in cases of protracted labor are pecu- 
liarly worthy of study, and have been very clearly pointed out by Dr. 
Braxton Hicks.^ He show^s that, when the pains have apparently 
fallen off and become few and feeble, or have entirely ceased, the uterus 
is in a state of continuous or tonic contraction, and that the irritation 
resulting from this is the chief cause of the more marked symptoms of 

1 Ohst. Trans., 1867, vol. ix. p. 207. 



PROLONGED AND PRECIPITATE LABORS. 345 

powerless labor. If in a case of the kind the uterus be examined by 
palpation, it will be found firmly contracted between the pains. The 
correctness of this observation is beyond question, and it will no doubt 
often be an important guide in treatment. Under such circumstances 
instrumental interference is imperatively demanded. 

Causes. — In considering the causes of protracted labor it will be 
well first to discuss those which affect the expulsive powers alone, leav- 
ing those depending on morbid states of the passages for future consid- 
eration ; bearing in mind, however, that the results as regards both the 
mother and the child are identical whatever may be the cause of delay. 

The general constitutional state of the patient may materially influ- 
ence the force and efficiency of the pains. Thus it not unfrequeutly 
happens that they are feeble and ineffective in women of very weak con- 
stitution or who are much exhausted by debilitating disease. Cazeaux 
pointed out that the effects of such general conditions are often more 
than counterbalanced by flaccid ity and want of resistance of the tissues, 
so that there is less obstacle to the passage of the child. Thus in phthisi- 
cal patients reduced to the last stage of exhaustion labor is not unfre- 
queutly surprisingly easy. 

Long residence in tropical climates causes uterine inertia, in conse- 
quence of the enfeebled nervous power it produces. It is a common 
observation that European residents in India ai'e peculiarly apt to 
suffer from post-partum hemorrhage from this cause. The general 
mode of life of patients has an unquestionable effect ; and it is certain 
that deficient and irregular uterine action is more common in women 
of the higher ranks of society, who lead luxurious, enervating lives, 
than in women whose habits are of a more healthy character. 

Tyler Smith lays much stress on frequent childbearing as a cause of 
inertia, pointing out that a uterus which has been very frequently sub- 
jected to the changes connected with pregnancy is unlikely to be in a 
typically normal condition. It is doubtful, however, whether the 
uterus of a perfectly healthy woman is affected in this way ; certainly, 
if childbearing had undermined her general health, the labors are likely 
to be modified also. 

Age has a decided effect. In the very young the pains are apt to be 
irregular, on account of imperfect development of the uterine nuiscle. 
Labor taking place for the first time in women advanced in life is also 
apt to be tedious, but not by any means so invariably as is generally 
believed. The apprehensions of sucli patients are often agreeablv 
falsified, and w^here delay does occur it is j)robably more often refer- 
able to rigidity and toughness of the parturient passages than to feeble- 
ness of the pains. 

Morbid states of the prinife vice frequently cause irregular, painful, 
and feeble contractions. A loaded state of the rectum has a remark- 
able influence, as evidenced by the sudden and distinct change in the 
character of the labor which often follows the use of suitable reuKxIies. 
Undue distension of the bladder may act in the same wav, more espe- 
cially in the second stage. When the urine has been alloweil to acru- 
niulate un(hily, the contraction of the accessory nuiscles of partiu'ition 
often causes such intense suflering, by compressing the distendtni viscus, 



346 LABOR. 

that the patient is absolutely unable to bear clown. Hence the labor is 
carried on by uterine contractions alone, slowly and at the expense of 
much suffering. A similar interference with the action of the accessory 
muscles is often produced by other causes. [We sometimes meet with 
what may be designated as recurrent uterine fatigue, in which the first 
stage of labor progresses slowly, w^ith intervals of entire suspension of 
uterine action, when the organ would appear to be taking a rest. Thi& 
peculiar irregularity may be found where the patient is in a fair degree 
of health and has not been enfeebled by any recognizable cause. In 
one very marked instance under my care in the higher walks of life 
labor came on at night, ceased in the morning, and was suspended for 
the day, the patient being up and about ; on the second night labor was 
renewed, to be followed by a second day of cessation. The third night 
I went to bed in the house, anticipating the possibility of a rapid second 
stage, in which I was not disappointed. As might also be looked for 
in such a case, there was a recurrence of uterine inertia an hour after 
the placenta came away, and a disposition to hemorrhage lasting for 
six hours. The child born was the third, and in the fourth labor 
there was no trouble of any kind. — Ed.] Thus if labor comes on 
when the patient is suffering from bronchitis or other chest disease she 
may be quite unable to fix the chest by a deep inspiration, and the dia- 
phragm and other accessory muscles cannot act. In the same way they 
may be prevented from acting when the abdomen is occupied by an 
ovarian tumor or by ascitic fluid. 

Mental conditions have a very marked eifect. This is so commonly 
observed that it is familiar to the merest beginner in midwifery prac- 
tice. The fact that the pains often diminish temporarily on the entrance 
of the accoucheur is known to every nurse ; and so also undue excite- 
ment, the presence of too many people in the room, overmuch talking, 
have often the same prejudicial effect. Depression of mind, as in 
unmarried women, and fear and despondency in women w^ho have 
looked forward with apprehension to the labor, are also common 
causes of irregular and defective action. 

Undue distension of the uterus from an excessive amount of liquor 
amnii not unfrequently retards the first stage, by preventing the uterus 
from contracting efficiently. When this exists, the pains are feeble and 
have little effect in dilating the cervix beyond a certain degree. This 
cause may be suspected when undue protraction of the first stage is 
associated with an unusually large size and marked fluctuation of the 
uterine tumor, through which the foetal limbs cannot be made out on 
palpation. On vaginal examination the lower segment of the uterus 
will be found to be very rounded and prominent, while the bag of 
membranes will not bulge through the os during the acme of the 
pain. 

A somewhat similar cause is undue obliquity of the uterus, which 
prevents the pains acting to the best mechanical advantage, and often 
retards the entry of the presenting part into the brim. The most com- 
mon variety is anteversion, resulting from undue laxity of the abdomi- 
nal parietes, which is especially found in women who have borne many 
children. Sometimes that is so excessive that the fundus lies over the 



PROLONGED AND PEECIFITATE LABORS. 347 

pubes^ and even projects downward toward the patient's knees. The 
consequence is, that when labor sets in, unless corrective means be taken, 
the pains force the head against the sacrum, instead of directing it into 
the axis of the pelvic inlet. Another common deviation is lateral 
obliquity, a certain degree of which exists in almost all cases, but 
sometimes it occurs to an excessive degree. Either of these states 
can readily be detected by palpation and vaginal examination com- 
bined. In the former the os may be so high up and tilted so far back- 
ward that it may be at first difficult to reach it at all. 

Irregular and Spasmodic Pains. — Besides being feeble, the uterine 
contractions, especially in the first stage, are often irregular and spas- 
modic, intensely painful, but producing little or no effect on the prog- 
ress of the labor. This kind of case has been already alluded to in 
treating of the use of anaesthetics (p. 299), and is very common in 
highly nervous and emotional women of the upper classes. In such 
cases cocaine has been of late used as a local application with decided 
benefit. It appears to act by deadening the pain resulting from the 
stretching of the nerves of the cervix or from slight cervical lacera- 
tions. It has no eifect in relieving the suffering caused by uterine 
contraction.^ It has been applied by means of a cotton-wool tampon 
steeped in a 2 per cent, solution and placed against the os. A 
much better way of using it is by *' Moore's cones," ^ made with 
cacoa butter, one of which is placed on the examining finger like a 
thimble and inserted within the os, where it rapidly melts. Such 
irregular contractions do not necessarily depend on mental causes 
alone, and they often follow conditions producing irritation, such as 
loaded bowels, too early rupture of the membranes, and the like. Dr. 
Trenholme of Montreal^ believes that such irregular pains most fre- 
quently depend on abnormal adhesions between the decidua and the 
uterine walls, which interfere with the proper dilatation of the os, and 
he has related some interesting cases in support of this theory. 

Treatment. — The mere enumeration of these various causes of pro- 
tracted labor will indicate the treatment required. Some of them, such 
as the constitutional state of the patient, age, or mental emotion, it is 
of course beyond the power of the practitioner to influence or modify ; 
but in every case of feeble or irregular uterine action a careful investi- 
gation should be made with the view of seeing if any removable cause 
exist. For example, the effect of a large enema when we suspect the 
existence of a loaded rectum is often very remarkable, the pains fre- 
quently almost immediately changing in character, and a previouslv 
lingering labor being rapidly terminated. 

Excessive distension of the uterus can only be treated by artificial 
evacuation of the liquor amnii ; and after this is done the character ot^ 
the pains often rapidly changes. This ex})edient is indeed often o\' con- 
siderable value in cases in which the cervix has dilattxl to a certain 
extent, but in which no further progress is made, especially if the hag 
of membranes does not jn'otrude through the os during the pains, and 

^"The Value of Cooaine in ObstotrKvs," by Joliu Phillips. H. A.. M. \\. iMiu-^t, 
November 2(5, 1887. 

'^Brii. J/<v/. Journ., 1S85, vol. ii. p. 1 140. » OlK<t. Ti\ui.<.. ]<::'. vol. xiv. p, '2'M. 



348 LABOR. 

the cervix itself is soft and apparently readily dilatable. Under such 
circumstances rupture of the membranes, even before the os fully dilated, 
is often very useful. 

If we have reason to suspect morbid adhesions between the mem- 
branes and the uterine walls, an endeavor must be made to separate 
them by sweeping the finger or a flexible catheter round the internal 
margin of the os or puncturing the sac. The former expedient has 
been advocated by Dr. Inglis ^ as a means of increasing the pains when 
the first stage is very tedious, and I have often practised it with marked 
success. Trenholme's observation affords a rationale of its action. The 
manoeuvre itself is easily accomplished, and, provided the os be not very 
high in the pelvis, does not give any pain or discomfort to the patient. 

Attention should always be paid to remedying any deviations of the 
uterus from its proper axis. If this be lateral, the proper course to 
pursue is to make the patient lie on the opposite side to that toward 
which the organ is pointing. In the more common anterior deviation 
she should lie on her back, so that the uterus may gravitate toward the 
spine, and a firm abdominal bandage should be applied. This prevents 
the organ from falling forward, while its pressure stimulates the mus- 
cular fibres to increased action ; hence it is often very serviceable when 
the pains are feeble, even if there be no anteversion. 

In a frequent class of cases, especially in the first stage, the pains 
diminish in force and frequency from fatigue, and the indication then is 
to give a temporary rest, after which they recommence with renewed 
vigor. Hence an opiate, such as 20 minims of Battley's solution, which 
often acts quickest when given in the form of enema, is frequently of the 
greatest possible value. If this secure a few hours' sleep, the patient 
will generally awake much refreshed and invigorated. It is important 
to distinguish this variety of arrested pain from that dependent on actual 
exhaustion ; and this can be done by attention to the general condition 
of the patient, and especially by observing that the uterus is soft and 
flaccid in the intervals between the pains, and that there is none of the 
tonic contraction indicated by persistent hardness of the uterine parietes. 
When the pains are irregular, spasmodic, and excessively painful, with- 
out producing any real effect, opiates are also of great service; and it is 
under such circumstances that chloral is especially valuable. 

Oxytocic Remedies. — Still, a large number of cases will arise in 
which the absence of all removable causes has been ascertained, and in 
which the pains are feeble and ineffective. We must now proceed to 
discuss their management. The fault being the want of sufficient con- 
traction, the first indication is to increase the force of the pains. Here 
the so-called oxytocic remedies come into action ; and, although a large 
number of these have been used from time to time, such as borax, cinna- 
mon, quinine, and galvanism, practically the only one in which reliance 
is generally placed is the ergot of rye. This has long been the favorite 
remedy for deficient uterine action, and it is a powerful stimulant of the 
uterine fibres. It has, however, very serious disadvantages, and it is 
very questionable whether the risks to both mother and child do not 
more than counterbalance any advantages attending its use. The 

^ Sydenham Society^s Year-Book, 1867, p. 399. 



PROLONGED AND PRECIPITATE LABORS. 349 

ergot is given in doses of 15 or 20 grains of the freslily-powdorc^d 
drug infused in warm water, or in the more convenient form of the 
liquid extract in doses of from 20 to 30 minims, or, still better, in 
the form of ergotine injected hypodermically, 3 to 4 minims of the 
hypodermic solution being used for the purpose. In about fifteen 
minutes after its administration the pains generally increase greatly 
in force and frequency, and if the head be low in the pelvis, and 
if the soft parts offer no resistance, the labor may be rapidly termi- 
nated. 

Were its use always followed by this effect there would be little or no 
objection to its administration. The pains, however, are different from 
those of natural labor, being strong, persistent, and constant. Its effect, 
indeed, is to produce that very state of tonic and persistent uterine con- 
traction which has already been pointed out as one of the chief dangers 
of protracted labor. Hence, if from any cause the exhibition of the 
drug be not followed by rapid delivery, a condition is produced which 
is serious to the mother and which is extremely perilous to the child, 
on account of the tonic contraction of the muscular fibres obstructing 
the utero-placental circulation. Dr. Hardy found that soon the foetal 
pulsations fall to 100, and if delivery be long delayed they commence 
to intermit. He also observed that when this occurred the child was 
always born dead, and found that the number of stillborn children 
after ergot has been exhibited was very large ; for out of 30 cases in 
which he gave it in tedious labor, only 10 of the children were born 
alive. Nor is its use by any means free from danger to the mother : 
a not inconsiderable number of cases of rupture of the uterus have 
been attributed to its incautious use. Hence, if it is to be given at 
all, it is obvious that it must be with strict limitations and after careful 
consideration. It is worthy of note that in the Rotunda Hospital in 
Dublin the use of ergot as an oxytocic before delivery has been pro- 
hibited by the present master. 

The cardinal point to remember is that it is absolutely contraindicated 
unless the absence of all obstacles to rapid delivery has been ascertained. 
Hence, it is only allowable when the first stage is over and the os fully 
dilated, when the experience of former labors has ])roved the pelvis to 
be of ample size, and when the perineum is soft and dilatable. Perhaps, 
as has been suggested, the administration of small doses of from 5 to 
10 minims of the liquid extract every ten minutes until more energetic 
action sets in might obviate some of these risks. 

The use of quinine as an oxytocic deserves much more attention than 
it has generally received. I frequently employ it in lingering labor 
with marked benefit, and it does not seem to have any of the bail 
effects of ergot. According to the observations of Dr. Albert II. 
Sniitli in 42 cases of parturition, it presented the following peculiar 
characteristics : 

It has no power in itself to excite uterine contractions, but simply 
acts as a general stimulant and })romoter of vital energy and t'unc- 
tional activity. 

In normal labor at full term its administration in a dose ot' tltioen 
grains is usually followed in as many minutes by a decided increase in 



360 LABOR. 

the force and frequeiicv of the uterine contractions, changing in some 
instances a tedious, exhausting labor into one of rapid enererv, advan- 
cing to an early completion. 

It promotes the permanent tonic contraction of the uterus after the 
expulsion of the placenta, women that had flooded in former labors 
escaping entirely, there not having been an instance of post-partum 
hemorrhage in the whole 42 cases. 

It also diminishes the lochial flow where it had been excessive in 
former labors, the change being remarked upon by the patients, and 
consequently lessens the severity of the after-pains. 

Cinchonism is very rarely observed as an effect of large doses in 
parturient women .^ 

Use of the Faradic Current. — The faradic current applied on either 
side of the uterine tumor, midway between the anterior superior spine 
of the ilium and the umbilicus, has recently been strongly recommended 
by Dr. Kilner,^ not only as a means of increasing uterine action, but 
of alleviating the sufferings of childbirth. I have tried it in several 
cases, but am not satisfied as to its possessing the properties attributed 
to it. 

If we had no other means of increasing defective uterine contrac- 
tions at our disposal, and if the choice lay only between the use of 
ergot and instrumental delivery, there might not be so much objection 
to a cautious use of the drug in suitable cases. We have, however, a 
means of increasing the force of the uterine contractions so much more 
manageable and so much more lesembliug the natural process that I 
believe it to be destined to entirely supersede the administration of 
ergot. This is the application of manual pressure to the uterus 
through the abdomen — an expedient that has of late years been much 
used in Germany and has begun to be employed in English practice. 
I believe, therefore, that ergot should be chiefly used for the purpose 
of exciting uterine contraction after delivery, when its peculiar pro- 
perty of promoting tonic contraction is so valuable, and that it should 
rarely, if at all, be employed betore the birth of the child. 

The systematic use of uterine pressure as an oxytocic was first promi- 
nently brought under the notice of the profession by Kristeller, under 
the name of " expressio fcetus,^^ although it has been used in various 
forms from time immemorial. Albucasis, for example, was clearly 
acquainted with its use, and referred to it in the following terms : 
^'Cum ergo vides ista signa, tunc oportet, ut comprimatur uterus ejus 
ut descendat embryo velociter." There are some curious obstetric 
customs among various nations which probably arose from a recog- 
nition of its value; as, for example, the mode of delivery adopted 
among the Kalmucks, where the patient sits at the foot of the bed 
while a woman, seated behind her, seizes her round the waist and 
squeezes the uterus during the pains. Amongst the Japanese, Siamese, 
Xorth American Indians, and many other nations pressure, applied in 
various ways, is habitually used. 

Kristeller maintains that it is possible to effect the complete expulsion 

1 Trans. Coll. Phys. Philad., 1875, p. 183. 

2 066-^ Trans., for 1884, vol. xxvi. p. 93. 



PROLONGED AND PRECIPITATE LABORS. 351 

of the child by properly applied pressure, even when the pains are 
entirely absent. Strange as this may appear to those who are not 
familiar with the effects of pressure, I believe that under exceptional 
circumstances, when the pelvis is very capacious and the soft parts 
offer but slight resistance, it can be done. I have delivered in this 
way a patient whose friends would not permit me to apply the forceps 
when I could not recognize the existence of any uterine contraction at 
all, the foetus being literally squeezed out of the uterus. It is not, 
however, as replacing absent pains, but as a means of intensifying and 
prolonging the effects of deficient and feeble ones, that pressure finds 
its best application. 

Its effects are often very remarkable, especially in women of slight 
build, where there is but little adipose tissue in the abdominal walls 
and not much resistence in the pelvic tissues. If the finger be placed 
on the head while pressure is applied to the uterus, a very marked 
descent can readily be felt, and not infrequently two or three applica- 
tions will force the head on to the perineum. There are, however, 
certain conditions when it is inapplicable, and the existence of which 
should contraindicate its use. Thus, if the uterus seem unusually 
tender on pressure, and, a fortiori, if the tonic contraction of exhaus- 
tion be present, it is inadmissible. So also if there be any obstruction 
to rapid delivery, either from narrowing of the pelvis or rigidity of 
the soft parts, it should not be used. The cases suitable for its applica- 
tion are those in which the head or breech is in the pelvic cavity, and 
the delay is simply due to a want of sufi&ciently strong expulsive 
action. 

It may be applied in two ways. The better plan is to place the 
patient on her back at the edge of the bed, and spread the palms of 
the hands on either side of the fundus and body of the uterus, and 
when a pain commences to make firm pressure during its continuance 
downward and backward in the direction of the pelvic inlet. As the 
oontraction passes off the pressure is relaxed, and again resumed when 
a fresh pain begins. In this way each pain is greatly intensified, and 
its effect on the progress of the foetus much increased. It is not essen- 
tial that the patient should lie on her back. A useful, although not so 
great, amount of pressure can be applied when she is lying in the 
ordinary obstetric position on her left side, the left hand being sjiroad 
out over the fundus, leaving the right free to watch the progress of the 
presenting part per vaginam. 

Special Value of Uterine Pressure. — The special value of this 
method of treating ineffective pains is, that the amount and frequency 
of the pressure are completely within the control of the practitii^ier, 
and arc capable of being regulated to a nicety in accordance with the 
requirements of each particular case. It has the peculiar advantage 
of closely imitating the natural means of delivery, and of being abso- 
lutely without risk to the child ; nor is there any reason to tiiink iliai 
it is capable of injuring the mother. At least I may sntely say tliat, 
out of the large number of rases in which I have used it, I have never 
seen one in which I had the least reason to think that it had pixn'txi 
hurtful. Of course it is essential not to use undue roughness ; firm 



352 LABOR. 

and even strong pressure may be employed, but that can be done ^yitll- 
out being rough, and, as its application is always intermittent, there is 
no time for it to inflict any injury on the uterine tissues. 

Pressure is specially valuable when it is desirable to intensify feeble 
pains. It may be serviceably employed when the pains are altogether 
absent to imitate and replace them, provided there be nothing but the 
absence of a vis a tergo to prevent speedy delivery. In such cases an 
endeavor should be made to imitate the pains as closely as possible by 
applying the pressure at intervals of four or five minutes, and entirely 
relaxing it after it has been applied for a few^ seconds. 

Instrumental Delivery. — AVhen all these means fail we have then 
left the resource of instrumental aid, and we have now to consider the 
indications for the use of the forceps under such circumstances. It has 
been already pointed out that professional opinion on this point has 
been undergoing a marked change, and that it is now recognized as an 
axiom by the most experienced teachers that when we are once con- 
vinced that the natural efforts are failing, and are unlikely to effect 
delivery except at the cost of long delay, it is far better to interfere 
soon rather than late, and thus prevent the occurrence of the serious 
symptoms accompanying protracted labor. The recent important 
debate on the use of the forceps at the Obstetrical Society of London 
remarkably illustrated these statements, for while there was much 
difference of opinion as to the advisability of applying the forceps 
when the head was high in the pelvis, a class of cases not noAv under 
consideration, it was very generally admitted that the modern teaching 
W'as based on correct scientific grounds. This is, of course, directly 
opposed to the view" so long taught in our standard works, in which in- 
strumental interference was strictly prohibited unless all hope of natural 
delivery was at an end ; and in which the commencement at least, if 
not the complete establishment, of symptoms of exhaustion was con- 
sidered to be the only justification for the aj)plication of the forceps in 
lingering labor. 

The reasons which have led the late distinguished master of the 
Rotunda Hospital to a more frequent use of the forceps are so well 
expressed in his report for 1872 that I venture to quote them as the 
best justification for a practice that many practitioners of the older 
school will no doubt be inclined to condemn as rash and hazardous. 
He says : ^ ^^ Our established rule is that so long as nature is able to 
effect its purpose without prejudice to the constitution of the patient, 
danger to the soft parts or the life of the child, we are in duty bound 
to allow the labor to proceed ; but as soon as we find the natural efforts 
are beginning to fail, and after having tried the milder means for relax- 
ing the parts or stimulating the uterus to increased action, and the 
desired effects not being produced, we consider we are in duty bound 
to adopt still prompter measures, and by our timely assistance relieve 
the sufferer from her distress and her offspring from an imminent 
death. Why, may I ask, should w^e permit a fellow-creature to under- 
go hours of torture when we have the means of relieving her wathin 
our reach? Why should she be allowed to Avaste her strength and 

^ Fourth Clinical Report of the Rotunda Lying-in Hospital for the Year ending 1872. 



PROLONGED ANT) PRECIPITATE LABORS. .353 

incur the risks consequent upon long pressure of the head on the soft 
parts, the tendency to inflammation and sloughing, or the danger of 
rupture, not to speak of the poisonous miasma whi(;h emanates from 
an inflammatory state of the passages, the result of tedious labor, and 
which is one of the fertile causes of puerperal fever and all its direful 
effects, attributed by some to the influence of being confined in a large 
maternity, and not to its proper source — i. e. the labor being allowed 
to continue till inflammatory symptoms appear ? The more we con- 
sider the benefits of timely interference and the good results which 
follow it, the more are we induced to pursue the system we have adopted, 
and to inculcate to those we are instructing the advantages to be gained 
by such practice, both in saving the life of the child as well as securing 
the greater safety of the mother." It would be impossible to put the 
matter in a stronger or clearer light, and I feel confident that these 
views will be indorsed by all who have adopted the more modern 
practice. 

BflPect of Early Interference on the Infantile Mortality. — In the 
first edition of this work I used the statistics of Dr. Hamilton of Fal- 
kirk and other modern writers as proving that a more frequent use of 
the forceps than had been customary diminished in a remarkable degree 
the infantile mortality. Dr. Galabin ^ has recently published an admir- 
able paper on this subject, in which, by a careful criticism of these 
figures, he has, I think, proved that the conclusions drawn from them 
are open to doubt, and that the saving of infantile life following more 
frequent forceps delivery is by no means so great as I had supposed. 
Dr. Roper in his remarks in the recent debate in the Obstetrical 
Society brought forward some strong arguments in support of the 
same view. This, however, does not in any way touch the main 
points at issue referred to in the preceding paragraph. 

Possible Dangers attending* the Use of the Forceps. — It is, of 
course, right that we should consider the opposite point of view, and 
reflect on the disadvantages which may attend the interference advo- 
cated. Here I should point out that I am now talking only of the use 
of the forceps in simple inertia, when the head is low in the pelvic 
cavity, and when all that is wanted is a slight vis ct froufc to sup])le- 
ment the deficient vis a tergo. The use of the instrument when the 
head is arrested high in the pelvis, or in cases of deformity, or befin-e 
tlie OS uteri is completely expanded, is an entirely different and nuich 
more serious matter, and does not enter into the present discussion. 
The chief question to decide is if there be suflicient risk to the mother 
to counterbalance that of delay. It will, of course, be conceded by 
all that the forcej)s in the hands of a coarse, bungling, and ignorant 
})ractitioner, who has not studied th<^ ]>roper mode of operating, mav 
easily inflict serious damage. The possibility of inflicting injury in 
this way should act as a warning to every obstetrician to make him- 
self thoroughly acquainted with the proper mode of using the in-trn- 
ment, and to accpiire the manual skill which practice and the studv 
of the mechanism of delivery will alone give; but it can hard Iv be 
used as an argument against its us(\ It' that wore adniitteJ, surgical 

^ Obstetrical Jonntal, 1877-78, vol. v. p. ThU. 
23 



354 LABOB. 

interference of any kind would be tabooed, since there is none that 
ignorance and incapacity might not render dangerous. 

Assuming, therefore, that the practitioner is able to apply the forceps 
skilfully, is there any inherent danger in its use ? I think all who dis- 
passionately consider the question must admit that in the class of cases 
alluded to the operation is so simple that its disadvantages cannot for a 
moment be weighed against those attending protraction and its conse- 
quences. Against this conclusion statistics may possibly be quoted, 
such as those of Churchill, who estimated that one in twenty mothei-s 
delivered by forceps in British practice were lost. But the fallacy of 
such figures is apparent on the slightest consideration ; and by no one 
has this been more conclusively shown than by Drs. Hicks and Phillips 
in their paper on tables of mortality after obstetric operations,' where it 
is proved in the clearest manner that such results are due not to the 
ti'eatment, but rather to the fact that the treatment was so long 
delayed. 

It is quite impossible to lay down any precise rule as to when the for- 
ceps should be used in uterine inertia. Each case must be treated on its 
own merits and after a careful estimate of the effects of the pains. The 
rules generally taught were that the head should be allowed to rest at or 
near the perineum for a number of hours, and that interference was 
contraindicated if the slightest progress Avere being made. It is needless 
to say that both of these rules are incompatible with the views I have 
been inculcating, and that any rule based upon the length of time the 
second stage of labor has lasted must necessarily be misleading. What 
has to be done, I conceive, is to watch the progress of the case anxiously 
after the second stage has fairly commenced, and to be guided by an 
estimate of the advance that is being made and the character of the 
pains, bearing in mind that the risk of the mother, and still more to the 
child, increases seriously with each hour that elapses. If we find the 
progress slow and unsatisfactory, the pains flagging and insufficient, and 
incapable of being intensified by the means indicated, then, provided the 
head be low in the pelvis, it is better to assist at once by the forceps, 
rather than to wait until we are driven to do so by the state of the 
patient.^ 

> out. Trans., 1872, vol. xiii. p. 55. 

- It may, perhaps, be of interest in connection with this important topic in practical 
midwifery if I reprint a letter I published some years ago in the Medical Times and 
Gazette. An historical case, snch as that of which it treats, will better illustrate the 
evil effects that may follow unnecessary delay than any amount of argument. It seems 
to me impossible to read the details of the delivery it describes without being forcibly 
struck with the disastrous results which followed the practice adopted, which, however, 
was strictly in accordance with that considered correct, up to a quite recent date, by the 
highest obstetric authorities : 

ON THE DEATH OF THE PEIXCESS CHAELOTTE OF WALES. 

(To the Editor of the Medical Times and Gazette.) 

Sir : The letter of your correspondent, "' An Old Accoucheur," regarding the death 
of the Princess Charlotte, raises a question of great interest — viz. whether the fatal 
result might have been averted under other treatment? The history of the case is 
most instructive, and I think a careful consideration of it leaves little room to doubt 
that, though the management of the labor was quite in accordance with the teaching 
of the day, it was entirely opposed to that of modern obstetric science. The following 



PROLONGED AND PRECIPITATE LABORS. 3^5 

[The late Dr. William Harris of Philadelphia said to the writer more 
than twenty-five years ago : '^ I am in the habit of using the forceps 

account of the labor may interest your readers, and will j)robably Ije new to most of 
them. It is contained in a letter from Dr. John Sims to the late Dr. Josejjh Clarke 
of Dublin: 

" LoNDOX, November 15, 1817. 

"My dear Sir : 1 do not wonder at your wishing to have a direct statement of the 
labor of Her Royal Highness the Princess Charlotte, the fatal issue of which has 
involved the whole nation in distress. You must excuse my Ijeing very concise, as I 
have been, and am, very nmch hurried. I take the opportunity of writing this in a 
lying-in chamber. Her Royal Highness' labor commenced by the discharge of the 
liquor amnii about seven o'clock on Monday evening, and the pains followed soon 
after. They continued through the night and a greater part of the next day — sharp, 
soft, but very ineffectual. Toward the evening Sir Richard Croft began to suspect that 
labor would not terminate without artificial assistance, and a message was despatched 
for me. I arrived at two on Wednesday morning. The labor was now advancing 
more favorably, and both Dr. Baillie and myself concurred in the opinion that it 
would not be advisable to inform Her Royal Highness of my arrival. From this time 
to the end of her labor the progress was uniform, though very slow, the patient in good 
spirits, the pulse calm, and there never was room to entertain a question about the use 
of instruments. About six in the afternoon the discharge became of a green color, 
which led to a suspicion that the child might be dead ; still, the giving assistance was 
-quite out of the question, as the pains now became more effectual, and the labor pro- 
ceeded regularly, though slowly. The child was born without artificial assistance at 
nine o'clock in the evening. Attempts were made for a good while to reanimate it by 
inflating the lungs, friction, hot baths, etc., but without effect ; the heart could not be 
made to beat even once. Soon after delivery Sir Richard Croft discovered that the 
uterus was contracted in the middle in the hour-glass form, and as some hemorrhage 
■commenced, it was agreed that the placenta should be brought away by introducing 
the hand. This was done about half an hour after the delivery of the cliild with more 
•ease and less blood than usual. Her Royal Highness continued well for about two 
hours ;• she then complained of being sick at stomach and of noise in the ears, began to 
be talkative, and her pulse became frequent ; but I understand she was very quiet 
after this and her pulse calm. About half-past twelve o'clock she complained of 
.severe pain in the chest, became extremely restless, with rapid, weak, and irregular 
pulse. At this time I saw her for the first time. It has been said that we had all 
gone to bed, but that is not a fact ; Croft did not leave her room, Baillie retired about 
eleven, and I went to my bedchamber and laid down in my clothes at twelve. Bv 
dissection some bloody fluid (two ounces) was found in the pericardium, supposed to 
be thrown out in articulo mortis. The brain and other organs all sound, except tlie 
right ovarium, which was distended into a cyst the size of a hen's egg. The hour- 
glass contraction of the uterus still visible, and a considerable quantity of blood in the 
cavity of the uterus — but those present dispute about the quantity, so much as from 
twelve ounces to a pound and a half — her uterus extending as high as her navel. The 
•cause of Her Royal Highness' death is certainly somewhat obscure ; the symptoms 
were such as attend death from hemorrhage, but the loss of blood did not seem to be suf- 
ficient to account for a fatal issue. It is possible that the eflusion into the pericardium 
took place earlier than was supposed, and it does not seem to be tpiite certain that this 
might not be the cause. That I did not see Her Royal Highness more early was awk- 
ward, and it would have been better that 1 had been introiluced betore the labor was 
expected ; and it should have been understood that when labor came on I should be 
jsent to without waiting to know whether a consultation was necessary or not. I 
thought so at the time, but 1 could not propose such an arrangement to Crot't. But 
this is entirely enire nous. I am glad to hear that your son is well, and, with all niv 
family, wish to be remembered to him. We were happy to hoar that he was agieoably 
married. 

" 1 remain, my iloar doctor. 

" Ever yours most truly. 

" John Sims. M. D. 

" This letter is confidential, as perhaps 1 might bo blamoil for writing any paviiou- 
Jars without the permission of Prince Leopold." 

What are the facts here shown ? Here was a ilelioato young wouian. propar<.Hl for 



356 LABOR. 

very frequently m my jiractice to aid in the delivery of delicate women : 
I would not like it to be generally known, for fear that it might be 
imitated by the unskilful ; but I use the instrument in about one out 
of seven cases of labor." In no forceps case had he a death among his 
own patients in thirty years. — Ed.] 

Precipitate Labor less Comraon than Lingering". — Undue rapidity 
of labor is certainly more uncommoli than its converse, but still it is by 
no means of unfrequent occurrence. Most obstetric works contain a 
formidable catalogue of evils that may attend it, such as rupture of the 
cervix, or even of the uterus itself, from the violence of the uterine 
action ; laceration of the perineum from the presenting part being 
driven through before dilatation has occurred ; fainting from the sud- 
den emptying of the uterus ; hemorrhage from the same cause. AVith 
regard to the child, it is held that the pressure to which it is stibjected^ 
and sudden expulsion while the mother is in the erect position, may 
l^rove injurious. Without denying that these results may possibly 
occur now and again, in the majority of cases over-rapid labor is not 
attended with any evil effects. 

Precipitate labor may generally be traced to one of two conditions, or 

the trial before her. as Baron Stockmar tells us. by '' lowering the organic strength of 
the mother by bleeding, aperients, and low diet,'' who was allowed to go on in linger- 
ing feeble labor for no less than fifty-two hours after the escape of the liquor amnii 1 
Such was the groundless dread of instrumental interference then prevalent that, 
although the case dragged on its weary length with feeble, inefibctual pains, every now 
and then increasing a little in intensity and then falling ofl'again. it is >tated " there never 
was room to entertain a question about the use of instruments." and even "' when the 

discharge became of a green color still, the giving assistance was quite out of 

the question " I Can any reasonable man dotibt that if the forceps had been employed 
hours and hours before — say on Tuesday, when the pains fell ofi'— the result would 
probably have been very difierent, and that the life of the child, destroyed by the 
enormously prolonged second stage, would have been saved ? It must be remembered 
that early on Tuesday morning delivery was expected, so that the head must then have 
been low in the pelvis ivide Stockmar's Jfemoirs, vol. i. p. 63'i. It would be difiicult to- 
find a case which more forcibly illustrates the danger of delay in the second stage of 
labor. Then what follows ? The uterus, exhausted by the lengthy efibrts it should 
have been spared, fails to contract efiectually. nor do we hear of any attempts to pro- 
duce contraction by pressure. The relaxed organ becomes full of clots extending up 
to the umbilicus, and all the most characteristic symptoms of concealed post-partum 
hemorrhage develop themselves. She complained "of being sick at stomach, and of 
noise in her ears, began to be talkative, and her pulse became frequent." Before long^ 
other symptoms came on, graphically described by Baron Stockmar. and which seem 
to point to the formation of a clot in the heart and pulmonary arteries — a mo^t likely 
occurrence after such a history. " Baillie sent me word that he wished me to see the 
princess. I liesitated. but at last went with him. She was suflering from spasms of the 
chest and difficulty of breathing, in great pain, and very restless, and threw herself 
continually from one side of the bed to the other, speaking now to Baillie, now to 
Croft. Baillie said to her. ' Here comes an old friend of yours.* She held out her left 
hand to me hastily, and pressed mine warmly twice. I felt her pulse ; it was going 
very fast — the beats now strong, now feeble, noAv intermittent.'' 

Here was evidently something different from the exhaustion of hemorrhage : and no 
one Avho has witnessed a case of pulmonary obstruction can fail to recognize in this 
account an accurate delineation of its dreadful symptoms. 

Surely this lamentable story can only lead to the conclusion that the unhappy and 
gifted princess fell a victim to the dread of that bugbear, " meddlesome midwifery,'* 
which has so long retarded the progress of obstetrics. 

I am, etc., 

W. S. Playfair. 

Curzon Street. Mayfair. W., November 29, 1872. 



PROLONGED AND PRECIPITATE LABORS. 357 

to a combination of both — excessive force and rapidity of the pains, or 
unusual laxity and want of resistance of the soft parts. The precise 
causes inducing these it is difficult to estimate. In some cases the for- 
mer may depend on an undue amount of nervous excitability, and the 
latter on the constitutional state of the patient tending to relaxation of 
the tissues. 

[As an instance of rapid delivery, I report the following case : In 
September, 1848, a 3-para of 27, in Philadelphia, was awakened in the 
night by a violent uterine pain, followed at once by a sensation of 
approaching delivery. Her husband, a noted accoucheur, was only uj) 
in time to receive the foetus, which came by the same pain that awakened 
his wife. A second foetus (both females) soon followed, and the whole 
labor, in all its stages, occupied but forty-five minutes. In two prior 
and two subsequent labors there was no marked haste in uterine action. 
The mother, who still lives, has never been a strong w^oman. — Ed.] 

Whatever the cause, the extreme rapidity of labor is occasionally 
remarkable, and one strong pain may be sufficient to effect the expul- 
sion of the child, with little or no preliminary warning. I have known 
a child to be expelled into the ])an of a water-closet, the only previous 
indication of commencing labor being a slight griping pain which led 
the mother to fancy that an action of the bowels was about to take 
place. More often there is what may be described as a storm of ute- 
rine contractions, one pain following the other with great intensity until 
the foetus is expelled. The natural effect of this is to produce a great 
amount of alarm or nervous excitement, which of itself forms one of the 
worst results of this class of labor. It is under such circumstances that 
temporary mania occurs, produced by the intensity of the suffering, under 
which the patient may commit acts her responsibility for which mav 
fairly be open to question. 

Little Treatment Possible. — Little can be done in treating undue 
rapidity of labor. We can, to some extent, modifv the intensity of the 
pains by urging the patient to refrain from voluntary eiforts and to 
open the glottis by crying out, so that the chest may no longer be a 
fixed point for muscular action. Opiates have been advised to control 
uterine action, but it is needless to point out that in most cases there is 
no time for them to take eflPect. Chloroform w^ill often be found most 
valuable, from the rapidity with which it can be exhibited ; and its 
power of diminishing uterine action, which forms one of its chief draw- 
backs in ordinary practice, will here prove of nuich service. 



358 LABOR. 



CHAPTER X. 

LABOR OBSTRUCTED BY FAULTY CONDITION OF THE SOFT 

PARTS. 

Rigidity of the Cervix a Frequent Cause of Protracted Labor. 
— One of the most frequent causes of delay in the first stage of labor 
is rigidity of the cervix uteri, which may depend on a variety of con- 
ditions. It is often produced by premature escape of the liquor amnii, 
in consequence of which the fluid wedge, which is Nature's means of 
dilating the os, is destroyed, and the hard presenting part is consequently 
brought to bear directly upon the tissues of the cervix, which are thus 
unduly irritated and thrown into a state of spasmodic contraction. At 
other times it may be due to constitutional peculiarities, among which 
there is none so common as a highly nervous and emotional tempera- 
ment, wiiich renders the patient 2)eculiarly sensitive to her sufferings and 
interferes with the harmonious action of the uterine fibres. The pains 
in such cases cause intense agony, are short and cramp-like in character^ 
but have little or no effect in producing dilatation, the os often remain- 
ing for many hours without an}' appreciable alteration, its edges being 
thin and tightly stretched over the head. Less often — and this is gen- 
erally met with in stout, plethoric women — the edges of the os are thick 
and tough. 

The effects of prolongation of labor from this cause will vary much 
under different circumstances. If the liquor amnii be prematurely 
evacuated, the presenting part presses directly upon the cervix, and the 
case is then practically the same as if the labor was in the second stage. 
Hence grave symptoms may soon develop themselves, and early interfer- 
ence may be imperatively demanded. If the membranes be unruptured, 
delay will be of comparatively little moment, and considerable time 
may elapse without serious detriment to either the mother or child. 

The treatment will naturally vary much with the cause and the 
state of the patient. In the majority of cases, especially if the mem- 
branes be still intact, patience and time are sufficient to overcome the 
obstacle ; but it is often in the power of the accoucheur materially to aid 
dilatation by appropriate management. Sometimes Nature overcomes 
the obstruction by lacerating the opposing structures ; and cases are on 
record in which even a complete ring of the cervix has been torn oiF and 
come away before the head. 

Many remedies have been recommended for facilitating dilatation, 
some of which no doubt act beneficially. Among those most frequently 
resorted to was venesection, and with it was generally associated the 
administration of nauseating doses of tartar emetic. Both these acted 
bv producing temporary depression, under which the resistance of the 
soft parts was lessened. They probably answer best in cases in which 
there was a rigid and tough cervix, and they might prove serviceable 



OBSTRUCTION FROM CONDITION OF SOFT PARTS. :io9 

even yet in stout, pletlioric women of robust frame. Practically^ tlicy 
are now seldom if ever employed, and other and less debilitating rem- 
edies are preferred. The agent, jjar excellence, most serviceable is chloral, 
which is of special value in the more common cases in which rigidity 
is associated with spasmodic contraction of the muscular fibres of the 
cervix. Two or three doses of 15 grains, repeated at intervals of 
twenty minutes, are often of almost magical efficacy, the pains becoming 
steady and regular, and the os gradually relaxing sufficiently to allow 
the passage of the head. Should the chloral be rejected by the stom- 
ach, it may be satisfactorily administered per rectum. Chloroform 
acts much in the same way, but on the whole less satisfactorily, its 
effects being often too great; while the peculiar value of chloral is its 
influence in promoting relaxation of the tissues without interfering with 
the strength of the pains. 

Various local means of treatment may be also advantageously used. 
One is the warm bath, which is much used in France. It is of unques- 
tionable value where there is mere rigidity, and may be used either as 
an entire bath, or as a hip-bath in which the patient sits from twenty 
minutes to half an hour. The objection is the fuss and excitement it 
causes, and for this reason it is an expedient seldom resorted to in this 
country. A similar effect is produced, and much more easily, by a 
douche of tepid water upon the cervix. This can be very easily admin- 
istered, the pipe of a Higginson^s syringe being guided up to the cervix 
by the index finger of the right hand, and a stream of water projected 
against it for five or ten minutes. Smearing: the os with extract of 
belladonna is advised by continental authorities, but its effects are more 
than doubtful. Horton ^ advocates the injection into the tissue of the 
cervix of -j-^ of a grain of atropine by means of a hypodermic syringe, 
and speaks very favcn-ably of the practice. 

Artificial Dilatation. — Artificial dilatation of the cervix by the 
finger has often been recommended, and has been the subject of 
much discussion, especially in the Edinburgh school, where it was 
formerly commonly employed. It is capable of being very useful, 
but it may also do much injury when roughly and injudiciously 
used. The class of cases in which it is most serviceable are those 
in which the liquor amnii has been long evacuated, and in which 
the head, covered by the tightly-stretched cervix, has descended low 
into the pelvic cavity. Under these circumstances, if the finger 
be passed gently within the os during a pain and its margin pressed 
upward and over the head, as it were, while the contraction lasts, 
the progress of the case may be materially facilitated. This ma- 
noeuvre is somewhat similar to that which lias been already spoken 
of, when the anterior lip of the cervix is caught between the head and 
the ])ubic bone, and if properly performed I believe it to be quite sate 
and often of great value. It is not, however, well adapted for those 
cases in which the membranes are still iiitael, or In which the os remains 
undilated when the head is still high in \\w pelvi>. When there i< 
much delay under tluese conditions, and interferenci^ oi' some kiinl 
seems called for, the dilatation may be nuieh assisted bv the use oi' 
' Amn: Joiirn. of Oh^t., 1S78, vol. xi. p. 4S-J. 



360 LABOR. 

caoutchouc dilators, described in the chapter on the induction of prema- 
ture labor, which imitate Nature's method of opening up the os, and 
also act as a direct stimulant to uterine contraction. But it should be 
remembered that it is precisely in such cases that delay is least prejudi- 
cial. If, however, the os be excessively long in opening, its dilatation 
may be safely and efficiently promoted by passing within it and dis- 
tending with water one of the smallest-sized bags ; and after this has 
been in position from ten to twenty minutes it may be removed, and a 
larger one substituted. 

Rigidity depending- upon Org-anic Causes. — Every now and again 
we meet with cases in which the obstacle depends upon organic changes 
in the cervix, the most common of which are cicatricial hardening from 
former lacerations, hypertrophic elongation of the cervix from disease 
antecedent to pregnancy, or even agglutination and closure of the os 
uteri. Cicatrices are generally the result of lacerations during former 
labors. They implicate a portion only of the cervix, which they render 
hard, rigid, and undilatable, while the remainder has its natural soft- 
ness. They can readily be made out by the examining finger. A 
somewhat similar, but much more formidable, obstruction is occasion- 
ally met with in cases of old-standing hypertrophic elongation of the 
cervix, wdiich is generally associated with prolapse. In most cases of 
this kind the cervix becomes softened during pregnancy, so that dila- 
tation occurs without any unusual difficulty. But this does not always 
happen. A good example is related by Mr. Roper in the seventh vol- 
ume of the Obstetrical Transactions (p. 233), in which such a cervix 
formed an almost insuperable obstacle to the passage of the child. 

Carcinoma of the cervix uteri, which produces extensive thickening 
and induration of its tissues, and even advanced malignant disease of 
the uterus, is no bar to conception. The relations of malignant disease 
to pregnancy and parturition have recently been well studied by Dr. Her- 
man,^ He concludes that cancer renders the patient inapt to conceive, 
but that when pregnancy does occur there is a tendency to the intra- 
uterine death and premature expulsion of the foetus, and the growth of 
the cancer is accelerated. When delivery is accomplished, naturally there 
is generally expansion of the cervix by Assuring of its tissue, but the 
harder forms of cancer may form an insuperable obstacle to delivery. 

Agglutination of the margins of the os uteri is occasionally met 
with, and must of course have occurred after conception. It is gen- 
erally the result of some inflammatory affection of the cervix during 
the early months of gestation, and I have known it to recur in the 
same woman in two successive pregnancies. Usually it is not asso- 
ciated with any hardness or rigidity, but the entire cervix is stretched 
over the presenting part, and forms a smooth covering in which the os 
may only exist as a small dimple, and may be very difficult to detect 
at all. Occlusion of the os uteri from inflammatory change sometimes 
so alters the cervix that no sign of the original opening can be dis- 
covered ; and in two such instances the Csesarean operation has been 
performed in the United States, by which the women were saved.^ 

* Obst. Trans., for 1878, vol. xx. p. 191. 
^ Harris' note to second American edition. 



OBSTRUCTION FROM CONDITION OF SOFT PARTS. 301 

Their Treatment. — Any of these mechanical causes of rigidity may 
at first be treated in the same way as the more simple cases ; and with 
patience, the use of chloral and chloroform, and of the fluid dilators 
sufficient expansion to permit the passage of the head will often take 
place. But if these methods produce no effect, and symptoms of con- 
stitutional irritation are beginning to develop themselves, other and 
more radical means of overcoming the obstruction may be required. 

Under such circumstances incision of the cervix may be not only jus- 
tifiable, but essential, and it frequently answers extremely well. On the 
Continent it is resorted to much more frequently and earlier than in 
England, and with the most beneficial results. The operation offers 
no difficulties. The simplest way of performing it is to guard the 
greater portion of the blade of a straight blunt-pointed bistoury by 
wrapping lint or adhesive plaster round it, leaving about half an inch of 
cutting edge toward its point. This is guided to the cervix on the under 
surface of the index fino^er, and three or four notches are cut in the cir- 
cumference of the os to about the depth of a quarter of an inch. Very 
generally, especially when the obstruction is only due to old cicatrices, the 
pains will now speedily effect complete expansion, which may be very 
advantageously aided by apj^lying the hydrostatic dilators. When the 
obstruction is due to carcinomatous infiltration or inflammatory thick- 
ening, the case is much more complicated, and will painfully tax the 
resources of the accoucheur. If it is possible, the disease should be 
remov^ed as much as can be safely done during pregnancy, which should 
also be brought to an end before the full period. During labor, incis- 
ions should form a preliminary to any subsequent proceedings that may 
be necessary, as they are, at the worst, not likely to increase in the least 
the risk the patient has to run, and they may possibly avert more serious 
operations. In the case of malignant disease the risk of serious hemor- 
rhage, from the great vascularity of the tissues, must not be forgotten, 
and if necessary means must be taken to check this by local styptics, 
such as perch loride of iron. If incision fail and the state of the 
patient demands speedy delivery, the forceps may be applied ; and 
Herman thinks they are, as a rule, better than turning. He also 
maintains that there is little difference in the risk to the mothers be- 
tween craniotomy and Csesarean section, and that the possibility of 
saving the child in cases in which incisions have failed should induce 
us to prefer the latter. 

[The experience of Great Britain would indicate that the Ca^sarean 
operation in cases of cancer of the cervix gives a better promise of 
success than in subjects having pelvic deformity. This result is proba- 
bly due to the operation in cases of cancer being in manv instances 
elective. — Ed.] 

Application of the Forceps within the Cervix. — Botorc perform- 
ing craniotomy, when the os is suiliciently open, a cautious application 
of the force})s is quite justitiable. Steady and careful downward trac- 
tion, combined with digital expansion, has often enabled a head to pass 
with safety through an os that has resisted all o{\wv means olMilatation. 
and the destruction of (lu> child has thus been avi>ided. If, indeed, the os 
a})pear to be dilatable, this procediuv may advantageously be adopttxl 



362 LABOR. 

before incision, and as a matter of fact it is commonly practised in the 
Rotunda Hospital. An operation involving, beyond doubt, of itself 
some risk, and requiring considerable operative dexterity, would natur- 
ally not be lightly and inconsiderately undertaken. But when it is 
remembered that the alternative is the destruction of the child, the risk 
of exhaustion, and at least as great mechanical injury to the mother, 
its difficulty need not stand in the way of its adoption. 

Treatment -when Occlusion of the Os Exists. — When the os is 
apparently obliterated, incision is the only resource. Before resorting 
to it the patient should be placed under chloroform and the entire lower 
segment of the uterus carefully explored. Possibly the aperture may 
be found high up and out of reach of an ordinary examination, or we 
may detect a depression corresponding to its site. A small crucial 
incision may then be made at the site of the os, if this can be ascer- 
tained ; if not, at the most prominent portion of the cervix. Very 
generally the pains will then suffice to complete expansion, which may 
be further aided by the fluid dilators. 

Ante-partum Hour-glass Contraction. — Dr. Hosmer ^ has drawn 
attention to a hitherto undescribed species of dystocia which he terms 
^^ ante-partum hour-glass contraction,^^ and which he believes to depend 
on constriction of the uterine fibres at the site of the internal os uteri. 
[Dr. Blundell (1840) refers to it in his Obstetric Medicine under the 
title of " circular contraction of the middle, of the wo7nb/^ dividing it 
as it were, into an upj^er and inferior chamber, part of the feet us 
lying in both. He had seen two or three cases. — Ed.] Harris^ 
doubts its limitation to the internal os uteri, and terms it " tetanoid 
falciform constriction of the uterus.''^ Whatever its site, in the cases 
recorded difficulties of the most formidable kind arose from this cause. 
The pelves were normal and the presentations natural, yet out of seven 
labors, four ended fatally, two before delivery. The constriction seems 
to have grasped the foetus with such force as to have rendered extraction 
either by the forceps or turning impossible. I have no personal experi- 
ence of this complication, which must fortunately be very rare. The 
introduction of the hand, the patient being deeply ansesthetized, would 
probably render diagnosis easy. The treatment must depend on the 
force and amount of constriction. If the constriction does not relax 
under chloroform, chloral, or the injection of atropine into the site of 
constriction, as recommended by Horton in rigidity of the cervix, turn- 
ing would probably be our best resource. Should this fail, the Csesarean 
section may be required to effect delivery, as happened in a case recorded 
by Dr. T. A. Foster of Portland, Maine. Gastro-elytrotomy is obviously 
unsuitable for such cases. 

Bands and Cicatrices in the Vagina. — Extreme rigidity of the 
vagina, or bands and cicatrices in or across its walls, the result of con- 
genital malformation, of injuries in former labors, or of antecedent 
disease, occasionally obstruct the second stage. There is seldom any 
really formidable difficulty from this cause, since the obstruction almost 
always yields to the pressure of the presenting part. If there be any 

^ Boston Med. and Surg. Journ., 1878, March and May. 
^ Harris' note to second American edition. 



OBSTRUCTION FROM CONDITION OF SOFT PARTS. '^63 

considerable extent of eicatrices in the vagina, artificial assistance may 
be required. If we should be aware of their existence during pregnancy 
and find them to be sufficiently dense and extensive to be likely to 
interfere with delivery, an endeavor may be made to dilate them gradu- 
ally by hydrostatic bags or bougies. If they be not detected until labor 
is in progress, we must be guided in our procedure by the pressure to 
which they are subjected. It may then be necessary to divide them with 
a knife and to hasten the passage of the head hy the forceps, so as to pre- 
vent contusion as much as possible. It is obviously impossible to lay 
down any positive rules for such rare contingencies, the treatment suit- 
able for which must necessarily vary much with the individual peculiar- 
ities of the case. 

Extreme Rig-idity of the Perineum. — Extreme rigidity of the 
perineum is often dependent upon cicatricial hardening from injury in 
previous labors. This condition may greatly interfere with its dilata- 
tion, and if laceration seems inevitable, we may be quite justified in 
attempting to avert it by incision of the margins of the perineum, 
on the principle of a clean cut being always preferable to a jagged 
tear. 

Labor complicated with Tumor. — Occasionally we meet with very 
formidable obstacles from tumors connected with the maternal structures. 
These are most commonly either fibroid or ovarian, although others 
may be met with, such as malignant growths from the pelvic bones, 
exostoses, etc. 

Considering the frequency with which women suffer from fibroid 
tumors of the uterus, it is perhaps somewhat remarkable that they do 
not more often complicate delivery. Probably women so affected are 
not apt to conceive. Occasionally, however, cases of this kind cause 
much anxiety. Of course the cases are most grave in which tumors 
are so situated as to encroach upon the cavity of the pelvis and mechani- 
cally obstruct the passage of the child. Even those in whicli this does 
not occur are by no means free from danger, for interstitial and subperi- 
toneal fibroids, situated in the upper parts of the uterus and leaving 
the pelvic cavity quite unimplicated, may interfere with the action of 
the uterine fibres, prevent subsequent contraction, cause profuse post- 
partum hemorrhage, or even predispose to rupture of the uterine tissues. 
Hence, every case in which the existence of uterine fibroids has been 
ascertained must be anxiously watched. The risk of henun-rhage is 
perhaps the greatest, for if the tumors be at all large efficient contrac- 
tion of the uterus after the birth of the child must be more or less 
interfered with. Fortunately, it is n(^t so common as might alnu^st be 
expected. Out of 5 cases recorded in the Ohsfcfrical Transacfio)).^, 2 
of which were in my own practice, no hemorrhage occurreil ; uov does 
it seem to have happencnl in any of the 2(> cases collected bv Mauih^- 
laine in his thesis on the subject. I recently saw an interestino- example 
of this in a patient whose case was looked lorward to with nnich anxiety 
in consequence of the existence of several enormous fibroid masses pro- 
jecting from the fundus and anterior surface of the btnly of the uterus, 
and whose labor was nev(M-llu>less typically normal in everv wav. 
Should hemorrhage occiu* after delivery, the injection oi' styptic sohuions 



364 LABOR. 

would probably be peculiarly valuable, since the ordinary means of 
promoting contraction are likely to fail. 

It is when the fibroid growths implicate the lower uterine zone and 
the cervical region that the greatest difficulties are likely to be met with. 
The practice then to be adopted must be regulated to a great extent by 
the nature of each individual case. If it be possible to push the tumor 
above the pelvic brim, out of the way of the presenting part, that, no 
doubt, is the best course to pursue, as not only clearing the passage in 
the most effectual way, but removing the tumor from the bruising to 
which it would otherwise be subjected when pressed between the head 
and the pelvic walls ; which seems to be one of the greatest dangers of 
this complication. This manoeuvre is sometimes possible under what seem 
to be the most unpromising circumstances. An interesting example is 
narrated by Sir Spencer Wells,^ who, called to perform the Csesarean 
section, succeeded, although not without much difficulty, in pushing the 
obstructing mass above the brim, the child subsequently passing with 
ease. I have myself elsewhere recorded two similar cases ^ in which I 
was enabled to deliver the patient by pushing up the obstructing tumor, 
in both of which the Csesarean section would have been inevitable had the 
attempt at reposition failed. Therefore, before resorting to more serious 
operative procedures a determined effort at pushing the tumor out of 
the way should be made, the patient being deeply chloroformed, and, if 
necessary, upward pressure being made by the closed fist passed into the 
vagina.^ 

Failing this, the possibility of enucleating the tumor, or, if that be 
not possible, of removing it piecemeal with the ecraseur, should be con- 
sidered. On account of the loose attachments of these growths, and the 
facility with which they can be removed in this way in the non-preg- 
nant state, the expedient seems certainly well worthy of a trial if their 
site and attachments render it at all feasible. Interesting examples of 
the successful performance of this operation are recorded by Danyau, 
Braxton Hicks, Lomer, and Munde. Should it be found impracticable, 
the case must be managed in reference to the amount of obstruction, 
and the forceps, craniotomy, or even one of the varieties of abdominal 
section, may be necessary (vide p. 228). 

[Csesarean records in cases of pelvic obstructions due to fibroid tumors 
show a very discouraging mortality. There have been 14 such opera- 
tions in the United States, Avith only 4 women and 5 children saved. 
Add these to 31 cases collected in 1882 by Dr. ]\Iax Sanger of Leipzig 
from other countries, and we have 45 cases Avith 36 deaths. An early 
operation under the Sanger method should be followed by better 
results. — Ed.] 

Tumors of the Ovaries. — The next most common class of obstruct- 
ing tumors are those of the ovary (Fig. 126), and it is apparently not 
the largest of these which are most apt to descend into the pelvic cavity. 
When the tumor is of any considerable size, its bulk is such that it 
cannot be contained in the true pelvis, and it rises into the abdominal 

^ Obst. Trans., 1867, vol. ix. p. 73. ^ Ibid, for 1877, vol. xix. p. 101. ^ 

^ This procedure is objected to in Dr. John Phillips' paper, already quoted, but it 
seems to me on insufficient grounds. 



OBSTRUCTION FROM CONDITION OF SOFT PARTS. 



365 



cavity with the uterus. Hence, the existence of the tumor that offers 
the most formidable obstacle to delivery is rarely suspected before labor 
sets in. 

In order to estimate the results of the various methods of treatment 
I have tabulated 57 cases.^ In 13, labor was terminated l^y the natural 
powers alone, but of these, 6 mothers, or nearly one-half, died. In 




Labor complicated by Ovarian Tumor. 

favorable contrast with these we gave the cases in which the size of the 
tumor was diminished by puncture. These are 9 in number, in all of 
which the mother recovered, 5 oat of the 6 children being saved. The 
reason of the great mortality in the former cases is apparently the 
bruising to which the tumor, even when small enough to allow the child 
to be squeezed past it, is necessarily subjected. This is extremely apt 
to set up a fatal form of diffuse inflammation, the risk of which was 
long ago pointed out by Ashwell,^ who draws a comparison between 
cases in which such tumors have been subjected to contusion and cases 
of strangulated hernia; and the cause of death in both is doubtless 
very similar. This danger is avoided when the tumor is punctured so 
as to become flattened between the head and the pelvic walls. On this 
account I think it should be laid down as a rule that i>uncture shouUl 
be performed in all cases of ovarian tumor engaged in front of the 
presenting part, even when it is of so small a size as not to ]>recludo 
the possibility of delivery by the natural powers. 

In 5 of the 57 cases it was found possible to return the tumor alnn-e 
the pelvic brim, and in these also the termination was very iavorable, 
all the mothers recovering. Should puncture not succeed — and it may 
fail on account of i\\o, gelatinous and scmi-st>lid nature of the contents 
of the cyst — it may be possible to dis[H>se o( the tumor in this wny. 
^ Ohi^t. 7V((/),s'., 18G7, vol ix. p. 09. "^ Cuus Uoqntal Rcporu<, vol. ii. 



366 LABOR. 

eveu wheu it seems to be iirmly wedged down in front of the present- 
ing part and to be hopelessly fixed in its unfavorable position. 

Failing either of these resources, it may be necessary to resort to 
craniotomy, provided the size of the tumor 23recludes the possibility of 
delivery by forceps. 

[A prolapsed dermoid cyst of large size may prove such an obstacle 
as to require delivery by abdominal section. This has happened but 
once in the United States, tlie cyst containing seventy hours after the 
operation half a gallon of pus. The patient was operated upon by Dr. 
Etheridge of Chicago on Feb. 21, 1888, and died in eighty-two hours. 
— Ed.] 

The question of the eifect on labor of ovarian tumor which does not 
obstruct the pelvic canal is one of some interest, but there are not a 
sufficient number of cases recorded to throw much light on it. I am 
disposed to think that labor generally goes on favorably. What delay 
there is depends on the inefficient action of the accessory muscles 
engaged in parturition, on account of the extreme distension of the 
abdomen. 

There are a few other conditions connected with the maternal struc- 
tures wdiich may impede delivery, but which are of comparatively rare 
occurrence. 

Amongst them is vaginal cystocele, consisting of a prolapse of 
the distended bladder in front of the presentation, where it forms a 
tense fluctuating pouch which has been mistaken for a hydrocej^halic 
head or for the bag of membranes. This complication is only likely to 
arise when the bladder has been allowed to become unduly distended 
from want of attention to the voiding of urine during labor. The diag- 
nosis should not offer any difficulty, for the finger will be able to pass 
behind, but not in front of, the swelling, and reach the presenting part, 
while the pain and tenesmus will further put the practitioner on his 
guard. The treatment consists in emptying the bladder, but there may 
be some difficulty in passing the catheter, in consequence of the urethra 
being dragged out of its natural direction. A long elastic male catheter 
Avill almost always pass if used with care and gentleness. Should it be 
found impossible to draw off the water — and this is said to have some- 
times happened — the tense pouch might be punctured without danger 
by the fine needle of an aspirator trocar and its contents withdrawn. 
AYhen once the viscus is emptied, it can easily be pushed above the 
presenting part in the intervals between the pains. 

In some few cases difficulties have arisen from the existence of a 
vesical calculus. Should this be pushed down in front of the head, 
it can readily be understood that the maternal structures would run the 
risk of being seriously bruised and injured. Should we make out the 
existence of a calculus — and if the presence of one be suspected the diag- 
nosis could easily be made by means of a sound — an endeavor should 
be made to push it above the brim of the pelvis. If that be found to 
be impossible, no resource is left but its removal, either by crushing or 
by rapid dilatation of the urethra, followed by extraction. Should we 
be aware of the existence of a calculus during pregnancy, its removal 
should certainlv be undertaken before labor sets in. 



OBSTRUCTION FROM CONDITION OF SOFT PARTS. 'U)7 

Hernial protrusion in Douglas' space may sometimes give rise to 
anxiety, from the pressure and contusion to which it is necessarily sub- 
jected. An endeavor must be made to replace it and to moderate the 
straining efforts of the patient ; and it may even be advisable to ap])ly 
the forceps so as to relieve the mass from pressure as soon as possible. 
li is, however, of great rarity. Fordyce Barker, in an interesting paper 
on the subject,^ records several examples, and states that he has met with 
no instance in which it has led to a fatal result, either to mother or 
child, although it cannot but be considered a serious complication. 

Scybalous masses in the intestines may be so hard and impacted 
as to form an obstruction. The necessity of attending to the state of the 
rectum has already been pointed out. Should it be found impossible to 
empty the bowel by large enemata, the mass must be mechanically 
broken down and removed by the scoop. 

[Our Southern readers are aware of the fact that their lowest class of 
women living in the country sometimes eat clay as a remedy for heart- 
burn, and occasionally in excessive quantities, during the pregnant 
state. Impacted clay in the lower bov/els has on two occasions proved 
such an obstacle to delivery that the Csesarean operation was performed, 
one case occurring in Louisiana and the other in Georgia, in the years 
18Q6 and 1882 respectively, after labors of sixty hours and three days. 
The first case recovered, the clay being removed by an attack of diar- 
rhfpa on the sixth day. The second died of convulsions in twenty days 
after the uterine and abdominal wounds had healed. Under chloi'o- 
form about two and a half pounds of sand and marl ^^ere removed 
three days after the operation. — Ed.] 

Excessive oedematous infiltration of the vulva may sometimes 
cause obstruction, and require diminution in size, which can easilv be 
•effected by numerous small punctures. 

Haematic effusions into the cellular tissue of the vulva or vagina 
form a grave complication of labor. Such blood-swellings are most 
usually met with in one or both labia or under the vaginal wall ; in the 
gravest forms the blood may extend into the tissues for a considerable 
distance, as in the case recorded by Cazcaux, where it reached upward 
as far as the umbilicus in front and as far as the attachment of the 
•diaphragm behind. 

The conditions associated with pregnancy, the distension and engorge- 
ment to which the vessels are subjected, the interference with the return 
of the blood by the pressure of the head during labc^r, and the violent 
efforts of the patient, afford a ready ex[)1anation of the reason wliy a ves- 
sel may be predisjwsed to rupture and admit of the extravasation oi' 
blood. 

The accident is fortunately far from a cc^mmon one, altliough a suf- 
ficient number of cases are recorded to make us familiar with its svmp- 
toms and risks. The dangers attending such effusions would stHMu to 
he great if the statistics given by thos(^ who have written ou tlie subjix't 
:uv to be trusted. Thus, out oi* 124 ceases collected by various French 
authors, 44 proved iatal. Fordyce Barker points out that since the 
nature and a[)])ro]>riate treatment of the ac^eident hnve Ihhmi more thor- 
' Amcr. Jouni. of Obst., 187(>, vol. i\. p. 177. 



368 LABOR. 

oiighly understood the mortality has been much lessened, for out of 15 
cases reported by Scanzoni, only 1 died, and out of 22 cases he had him- 
self seen, 2 died ; and all these three deaths were from puerperal feyer, 
and not the direct result of the accident.^ 

The blood may be effused into any part of the pelyic cellular tissue 
or into the labia. The accident most often happens during labor when 
the head is low down in the pelyis, not unfrequently just as it is about 
to escape from the vulva. Hence the extravasation is more often met 
with low down in the vagina, and more frequently in one of the labia 
than in any other situation. I have met with a case in which I had 
every reason to believe that an extravasation of blood had occurred 
within the tissues immediately surrounding the cervix. It is natural to 
suppose that a varicose condition of the veins about the vulva would 
predispose to the accident, but in most of the recorded examples this is 
not stated to have been the case. Still, if varicose veins exist to any 
marked degree, some anxiety on this point cannot but be felt. 

The thrombus occasionally, though rarely, forms before delivery. 
Most commonly it first forms toward the end of labor or after the birth 
of the child. In the latter case it is probable that the laceration in the 
vessels occurred before the birth of the child, and that the pressure of 
the presenting part prevented the escape of any quantity of blood at the 
time of laceration. 

The S3miptoins are not by any means characteristic. Pain of a 
tearing character, occasionally xqyy intense, and extending to the back 
and down the thighs, is very generally associated with the formation of 
the thrombus. If a careful physical examination be made the nature of 
the case can readily be detected. When the blood escapes into the 
labium, a firm, hard swelling is felt, which has even been mistaken for 
the foetal head. If the effusion implicate the internal parts only, the 
diagnosis may not at first be so evident. But even then a little care 
should prevent any mistake, for the swelling may be felt in the vagina, 
and may even form an obstacle to the passage of the child. Gazeaux 
mentions cases in w^hich it was so extensive as to compress the rectum 
and urethra, and even to prevent the exit of the lochia. In some cases 
the distension of the tissues is so great that they lacerate, and then hem- 
orrhage, sometimes so profuse as directly to imperil the life of the 
patient, may occur. The bursting of the skin may take place some time 
subsequent to the formation of the thrombus. Constitutional symptoms 
will be in proportion to the amount of blood lost, either by extravasa- 
tion or externally, after the rupture of the superficial tissues. Occasion- 
ally they are considerable, and are the same as those of hemorrhage 
from any cause. 

The termination of thrombus is either spontaneous absorption, which 
may occur if the amount of blood extravasated be small ; or the tumor 
may burst, and then there is external hemorrhage ; or it may suppurate, 
the contained coagula being discharged from the cavity of the cyst ; or, 
finally, sloughing of the superficial tissues has occurred. 

The treatment must naturally vary with the size of the thrombus 
and the time at which it forms. If it be met with during labor, unless 

^ The Puerperal Diseases, p. 60. 



OBSTRUCTION FROM CONDITION OF SOFT PARTS 369 

it be extremely small, it will be very apt to form an obstruction to the 
passage of the child. Under such circumstances it is clearly advisal^le 
to terminate the labor as soon as possible, so as to remove the obstacle 
to the circulation in the vessels. For this purpose the forceps should 
be applied as soon as the head can be easily reached. If the tumor 
itself obstruct the passage of the head or if it be of any considerable size, 
it will be necessary to incise it freely at its most ])rominent point and 
turn out the coagula, controlling the hemorrhage at once by filling the 
cavity with cotton wadding saturated in a solution of j^erchloride of 
iron, while at the same time digital compression with the tips of the fin- 
gers is kept up. By this means pressure is applied directly to the 
bleeding point, and the hemorrhage can be controlled without difficulty. 
This is all the more necessary if spontaneous rupture have taken place, 
for then the loss of blood is often profuse, and it is of the utmost 
importance to reach the site of the hemorrhage as early as ])ossible. 

If the thrombus be not so large as to obstruct delivery, or if it be not 
detected until after the birth of the child, the question arises whether 
the case should not be left alone, in the hope that absorption may 
occur, as in most cases of pelvic hsematocele. This expectant treatment 
is advised by Cazeaux, and it seems to be the most rational plan we 
can adopt. True, it may take a longer time for the patient to conva- 
lesce completely than if the coagula were removed at once and the hem- 
orrhage restrained by pressure on the bleeding point ; but this disad- 
vantage is more than counterbalanced by the absence of risk from 
hemorrhage, and of septicaemia from the suppuration that must neces- 
sarily follow. Softening and suppuration may in many cases occur in 
a few days, necessitating operation, but the vessels will then be probably 
occluded and the risk of hemorrhage much lessened. Dr. Fordyce 
Barker, however, holds the opposite opinion, and thinks that the proper 
plan is to open the thrombus only, controlling the hemorrhage in the 
manner already indicated, unless the thrombus is situated high in the 
vaginal canal. 

Whenever the cavity of a thrombus has been opened, either by incision 
or by spontaneous softening at some time subsequent to its formation, it 
must not be forgotten that there is considerable risk of septic absorp- 
tion. To avoid this, care must be taken to use antiseptic dressings 
freely, such as iodoform powder or avooI, apj)lied directly to the part, 
and frequent vaginal injections of diluted C'ondy's fluid. Barker lays 
special stress on the importance of not removing prematurely the ooagida 
formed by the styptic applications, for fear of secondary liemorrhage, but 
of allowing them to come away spontaneously. 

[Polypus. — Large uterine polyin may act as serious obstaok^s to 
delivery. When sufficiently long in ]HHliek% a polypus may bo ex- 
truded before the head of the f(rtus. The tumor may also be dotaclKxl 
in its expulsion, or may be removed by an ^craseur if iwognizai in 
time: it may also be pushed up out of the way and secured by bringing 
down the child. I once re})laced a large polypus that was oxtrudtnl botore 
the head, and the woman carried it two years longer; by which time, 
being nuich wasted by 'the discharge, she made up her mind to have it 
removed. — Ed.] 

24 



370 



LABOR. 



CHAPTEK XI. 

DIFFICULT LABOR DEPENDING ON SOME UNUSUAL CONDITION 

OF THE FCETUS. 



Fig. 127. 



Plural Births. — The subject of multiple pregnancy in general having 
already been fully considered, we have now only to discuss its practical 
bearing as regards labor. Fortunately, the existence of twins rarely 
gives rise to any serious difficulty. In the large proportion of cases the 
presence of a second foetus is not suspected until the birth of the first, 
when the nature of the case is at once apparent from the fact of the 
uterus remaining as large, or nearly as large, as it Avas before. 

There may possibly be some delay in the birth of the first child, inas- 
much as the extreme distension of the uterus may interfere with its 
thoroughly efficient action; while, in addition, the uterine pressure is not 

directly conveyed to the ovum as in single 
births, but indirectly through the amniotic 
sac of the second child (Fig. 127). Such 
delay is especially apt to arise when the 
first child presents by the breech, for even 
if the body be expelled spontaneously, 
difficulty is likely to occur with the head, 
since the uterus does not contract upon it, 
as is ordinarily the case. Hence, the in- 
tervention of the accoucheur to save the 
life of the child by the extraction of the 
head will be almost a matter of necessity. 
In the majority of cases, after the birth 
of the first child there is a temporary lull 
in the pains, which soon recommence, 
generally in from ten to twenty minutes, 
and the second child is rapidly expelled, 
for on account of the full dilatation of the 
soft parts there is no obstacle to its delivery. 
Sometimes there is a considerable interval 
Twin Pregnancy, Breech and Head before the paius rccur, and instauccs are 

Presenting. .r , . , ' i -■ 

recorded m which even several days 
elapsed between the births of the two children. 

Treatraent. — In most cases the management of twins does not differ 
from that of ordinary labor. As soon as we are certain of the existence 
of a second foetus we should inform the bystanders, but not necessarily 
the mother, to whom the news might prove an unpleasant and even 
dangerous shock. Then, having taken care to tie the cord of the first 
child for fear of vascular communication between the placentae, our duty 
is to wait for a recurrence of the pains. If these come on rapidly and 




DYSTOCIA FROM FOETUS. 371 

the presentation of the second foetus be normal^ its birth is managed in 
the usual way. 

If there be any unusual delay we have to consider the proper course 
to pursue, and on this the opinions of authorities differ greatly. Some 
advise a delay of several hours, and even more, if pains do not recur 
spontaneously; while others — Murphy, for example — recommend that 
the second child should be delivered at once. Either extreme of prac- 
tice is probably wrong, and the safest and best course is doubtless the 
medium one. The second point to bear in mind is, that in multiple 
pregnancy, on account of the extreme distension of the uterus, there is 
a tendency to inertia, and consequently to post-partum hemorrhage, 
and that, therefore, it is better that the birth of the second child should 
be delayed, even for a considerable time, rather than that the patient 
should run the risk attending an empty and uncontracted uterus. If, 
however, uterine action be present, there is an obvious advantage in the 
delivery of the second child before the dilatation of the passages passes 
off. 

The best plan would seem to be if, after waiting a quarter of an hour, 
labor-pains do not occur, to try and induce them by uterine friction and 
pressure and by the administration of a dose of ergot, to which, as there 
can be no obstacle to the rapid birth of the second child, there can be 
now no objection. The membranes of the second child should always 
be ruptured at once, if easily within reach, as one of the speediest means 
of inducing contraction. If no progress be made and speedy delivery 
be indicated — a necessity which may arise either from the exhausted 
state of the patient, the presence of hemorrhage, extremely feeble pul- 
sations of the foetal heart (showing that the life of the second child is 
endangered), or malpresentations of the second foetus — turning is prob- 
ably the readiest and safest expedient. Under such circumstances the 
operation is performed with great ease, since the passages are amply 
dilated. After bringing down the feet the birth of the body should be 
slowly effected, with the view of ensuring as complete subsequent con- 
traction as possible. If the head has descended in the pelvis, of coui-se 
turning is impossible and the forceps must be ap}")lied. 

Difficulties arising- from Locked Twins. — Occasionally very seri- 
ous difficulties arise from parts of both foetuses presenting sinuiltane- 
ously, and thus impeding the entrance of either child into the pelvis, 
or getting locked together, so as to render delivery impossible without 
artificial aid. Such difficulties are not apt to arise in the more ordinary 
cases, in which each child has its own bag of membranes, since then the 
foetuses are kept entirely separate, but in those in which the twins are 
contained in a common amniotic cavity or in which both sacs have burst 
simultaneously. They are very puzzling to the obstetrician, and it niav 
be far from easy to discover the cause of the obstruction. Xor is it ]his- 
sible to lay down any positive rules for their managomont, which nmst 
be governed to a considerable extent by the circumstances o( each indi- 
vidual case. 

Sometimes both heads ])resent simultaneously at the brim, and then 
neither can enter unless they be unusually small or the pelvis verv 
capacious, when both may descend ; or rather the tirst head mav descvnd 



372 



LABOR. 



low into the pelvic cavity^ and then the second head enters the brim and 
gets jammed against the thorax of the first child (Fig. 128). Reimann^ 
relates a ctirious example of this in which he delivered the head first 



Fig. 128. 




Shows Head-locking, both children presenting head first. (After Barnes.) 



"with the force]3S, but found the body would not follow^ and on exami- 
nation a second head was found in the pelvis. He then applied the for- 
ceps to the second head ; the body of the first child was then born^ and 
afterward that of the second. Such a mechanism must clearly have been 
impossible unless the pelvis had been extremely large. 

Whenever both heads are felt at the brim it will generally be found 
possible to get one out of the way by appropriate manipulation, one 
hand being passed into the vagina, the other aiding its action from 
without. Then the forceps may be applied to the other head, so as to 
engage it at once in the pelvic cavity. If both have actually passed 
into the pelvis, as in the case just alluded to, the difficulty will be much 
greater. It will generally be easier to push up the second head, while 
the lower is drawn out by the forceps, than to deliver the second, leav- 
ing the first in situ. 

In other cases a foot or hand may descend along with the head, and 
even the four feet may present simultaneously. The rule in the former 
case is to push the part descending with the head out of the way, and 
in the latter to disengage one child as soon as possible. Great care is 
necessary, or we might possibly bring down the limbs of separate 
children. 

The most common kind of difficult}' is when the first child presents 
by the breech, and is delivered as far as the head, which is then found 

^ Arch. f. Gyndk., 1871, Bd. ii. p. 99. 



DYSTOCIA FROM FCETUS. 373 

to be locked with the head of the second child, which has descended 
into the pelvic cavity (Fig. 129). 

Here it is clear that the obstruction must be very great, and, unless 
the children are extremely small, insuperable. The first endeavor 
should be to disentangle the heads: this is sometimes feasible if the 
second be not deeply engaged in the pelvis and the hand be passed up 

Fig. 129. 




Shows Head-locking, first child coming foot tirsst ; impaction of heads from wedging 

in brim. (After Barnes.) 

D. Apex of wedge, e, c. Base of wedge, which cannot outer brim. a. b. Line of decapitation to decompose 

wedge and enable head of second child to pass. 

SO as to push it out of the way. This will but rarely succeed : thou it 
may be possible to apply the forceps to the secoml head and drag it past 
the body of the first child ; and this js the method rocommoiukxl by 
lieimann, who has written an excellent paper on the subject.^ Gen- 
erally, t\\Q sacrifice of one of the children is essential, and as the Ixxiv 
of the first child must 'have been born for some time, it is probable 
that the pressure to which it has been subjected Mill have already 
' Americnn Journal of Obs(t(ru\<, 1S77. vol. x. p. 47. 



374 LABOR. 

imperilled^ if it has not destroyed^ its life, and therefore the plan 
usually recommended is to decapitate. This can easily be done Avitb 
scissors or a wire ecraseur, after which the second child is exj^elled 
without difficulty, leaving the head of the first in utero to be subse- 
quently dealt with. 

Another mode of managing these cases is to perforate the upper head 
and draw it past the lower with the cephalotribe or craniotomy forceps. 
This plan has the disadvantage of probably sacrificing both children, 
since the other child can hardly survive the pressure and delay ; where- 
as the former plan gives the second child a fair chance of being born 
alive. 

Double Monsters. — In connection with the subject of twin labor 
we may consider those rare cases in which the bodies of the foetuses 
are partially fused together. The mechanism and management of 
delivery in cases of double monstrosity^ have attracted comparatively 
little attention, no doubt because authors have considered them matters 
of curiosity merely, rather than of practical importance. 

The frequent occurrence of such monstrosities in our museums, and 
the niunerotts cases scattered through our periodical literature, are suf- 
ficient to show that they are not so very rare as we might be inclined 
to imagine : and, as they are likely to give rise to formidable difficul- 
ties in delivery, it cannot be unimportant to have a clear idea of the 
usual course taken by nature in effecting such births, with a view of 
enabling us to assist in the most satisfactory manner should a similar 
case come under our observation. 

Unfortunately, the authors who have placed on record the birth of 
double monsters have generally occupied themselves more with a descrip- 
tion of the structural peculiarities of the foetuses than with the mechan- 
ism of their delivery ; so that, although the cases to be met with in 
medical literature are very numerous, comparatively few of them are 
of real value from an obstetric point of view. Still, I have been able 
to collect the details of a considerable number ^ in which the history of 
the labor is more or less accurately described ; and doubtless a more 
extensive research would increase the list. 

Double Monstrosity may be Divided into Four Classes. — For 
obstetric j^urposes we may confine our attention to four principal varie- 
ties of double monstrosit}' which are met with far more frequently than 
any others. These are : 

A. Two nearly separate bodies united in front, to a varying extent, 
by thorax or abdomen. 

B. Two nearly separate bodies united back to back by the sacrum 
and lower part of the spinal column. 

C. Dicephalous monsters, the bodies being single below, but the 
heads separate. 

D. The bodies separate below, but the heads partially united. 

This classification by no means includes all the varieties of monsters 
that we meet with. It does, however, include all that are likely to give 
rise to much difficulty in delivery ; and all the cases I have collected 
may be placed under one of these divisions. 

^ Obst. Trans., 1867, vol. viii. p. 300. 



DYSTOCIA FROM FCETUS. 375 

The first point that strikes us in looking over the history of tliese 
deliveries is the frequency with which they have been terminated by 
the natural powers alone, without any assistance on the part of the 
accoucheur. Thus, out of the 31 cases, no less than 20 were delivered 
naturally, and apparently without much trouble. Nothing can better 
show the wonderful resources of nature in overcoming difficulties of a 
very formidable kind. 

It is pretty generally assumed by authors that the children are neces- 
sarily premature, and therefore of small size, and that delivery before 
the full term is rather the rule than the exception. Duges states that 
the children are often dead, and that putrefaction has taken place, 
which facilitates their expulsion. Both these assumptions seem to me 
to have been made without sufficient authority, and not to be borne out 
by the recorded facts. In only 1 of the 31 cases it is mentioned that 
the children were premature; nor is there any sufficient reason that I 
can see why labor should commence before the full term of gestation. 

Class A. — By far the greatest number are included in the first class 
— that in which the bodies are nearly separate, but united by some part 
of the thorax or abdomen. This is the division which includes the 
celebrated Siamese Twins, an account of whose birth, I may observe, 
I have not been able to discover.^ Out of the 31 cases, 19 come under 
this heading. The details of the labors are briefly as follows: 1 died 
undelivered ; 8 were terminated by the natural powers, in 3 of which 
the feet, and in 3 the head, presented ; in 2 the presentation is doubt- 
ful ; 6 were delivered by turning or by traction on the lower extremi- 
ties; 4 were delivered instrumentally. 

The details of the cases in which the feet presented or in ^vhich turn- 
ing was performed clearly show that footling presentation ^vas by far 
the most favorable; and it is fortunate that the feet often present 
naturally. The inference of course is that version should be resorted 
to whenever any other presentation is met with in cases of double mon- 
strosity of this type; but, unfortunately, this rule could rarely be 
carried into execution, since we possess no means of diagnosing the 
junction of the foetuses at a sufficiently early stage of labor to admit 
of turning being performed. It is only under exceptionally favon\ble 
circumstances that this can be done ; as, for example, in a case recorded 
by Molas, in which both heads presented, but neither would enter the 
brim of the pelvis. 

The great difficulty must, of course, be in the delivery of the heads, 
for in all the recorded cases, with one exception, the bodies have i>asseil 
through the pelvis })arallel to each other with comparative ease until 
the necks have appeared, and then, as a rule, they could bo brought no 

[' Tlie mother of these twins was once seen by Dr. Kusolieuberger of Phihulolpliia 
at Bangkok : slie was a (^hinese half-breed, short, and with a broad pelvis, ami had 
borne several children previonsly. She stated on several occasions, in convei-saiiiMi 
with parties in Siani, that the twins were born revei'sed. the feet of one being followed 
by the head of the other, and that they were very small and teeble at birth and tor 
several months afterward. The twins conlirmed this statement by atlirming that they 
could, when little boys at play on the ground, turn themselves end lor end upon the 
ensiform attachment up to the age of tea or twelve, the attachn\ent being then sotl 
and pliable. Although called Siamese, they were three-quarters t'hincse. — Ki\J 



376 LABOR. 

farther. It is clear that the remainder of the foetuses could no longer 
pass simultaneously, and were direct traction continued the heads would 
be inextricably fixed above the brim. In accordance with the direction 
of the pelvic axes the posterior head must first engage in the inlet ; and 
in order to effect this it will be necessary to carry the bodies of the 
children well over the abdomen of the mother. This seems to be a 
point of primary importance. It would also be advisable to see that 
the bodies are made to pass through the pelvis with their backs in the 
oblique diameter. By this means more space is gained than if the 
backs were placed antero-posteriorly, while at the same time there is 
less chance of the heads hitching against the promontory of the sacrum 
and symphysis pubis, which otherwise would be very apt to occur. 

When the head presents and the labor is terminated by the natural 
powers, delivery seems to be accomplished in one of two ways: 

In the first and more common the head and shoulders of one child 
are born, its breech and legs being subsequently pushed through the 
pelvis by a process similar to that of spontaneous evolution ; and after- 
ward the second child probably passes footling without much difficulty. 

Barkow relates a case in which both heads were delivered by the for- 
ceps, the bodies subsequently passing simultaneously. Two similar 
instances are recorded in the third and sixth volumes of the Obstetrical 
Transactions. When delivery takes place in this manner the head of 
the second child must fit into the cavity formed by the neck of the first, 
and the pelvis must necessarily be sufficiently roomy to admit of the 
expulsion of the head of the second child, while its cavity is dimin- 
ished in size by the presence of the neck and shoulders of the first. 
Either of these processes must obviously require exceptionally favor- 
able conditions as regards the size of the child and the pelvis, and the 
difficulty in the way of delivery must be nmch greater than when the 
lower extremities present. Therefore I think the rule should be laid 
down that when the nature of the case is made out (and for the pur- 
pose of accurate diagnosis a complete examination under anaesthesia 
should be practised) turning should be performed and the feet brought 
down. 

In the event of its being found impossible to effect delivery after a 
considerable portion of the bodies is born, no resource remains but 
the mutilation of the body of one child, so as to admit of the passage 
of the other. This was found necessary in one case in which the 
children presented by the feet and Avere born as far as the thorax, but 
could get no farther. The body of the anterior child was removed 
by a circular incision as far as it had been expelled, which allowed the 
remaining portion, consisting of the head and shoulders, to re-enter the 
uterus ; after this the posterior child was easily extracted, and the 
mutilated foetus followed without difficulty. 

Class B. — In Class B, in w^iich the children are united back to back, 
3 cases are recorded, all of w^hich were delivered by the natural powers. 
One of these is the case of Judith and Helene, the celebrated Hun- 
garian twins, who lived to the age of twenty-one. Helene was born 
as far as the umbilicus, and after the lapse of three hours her breech 
and legs descended. Judith was expelled immediately afterward, her 



DYSTOCIA FROM FfETUS. Zll 

feet descending first.[^] Exactly the same process occurred in a case 
described by M. Norman, tlie children being also born alive, and 
dying on the ninth day. 

It is probable that labor is easier in this case of double monsters than 
in the former, because the children are so joined that there is no neces- 
sity for the bodies to be parallel to each other during birth when the 
head presents, and after the birth of the head and shoulders of the first 
child its breech and lower extremities are evidently pushed down and 
expelled by a process of spontaneous evolution. If the feet originally 
presented, the mechanism of delivery and the rules to be followed 
would be the same as in Class A; but the difficulty would probably 
be greater, since tlie juncture is not so flexible, and a more complete 
parallelism of the bodies would be necessary during extraction. 

Class C. — In Class C, that of the dicephalous monster, I have found 
the description of the birth of 8 cases, 3 of which were terminated by 
the natural powers. In 2 of these cases the process of evolution was 
the main agent in delivery, one head being born and becoming fixed 
under the arch of the pubes, the body being subsequently pushed past 
it, and the second head following without difficulty. This process fail- 
ing, the proper course is to decapitate the first-born head, and then 
bring down the feet of the child, when delivery can be accomplished 
with ease. This was the course adopted in 2 out of the 8 cases ; and 
it may be done with the less hesitation since, from their structural 
peculiarities, it is extremely improbable that monsters of this kind 
should survive. In the third case, terminated naturally, the heads 
were said to have been born simultaneously, but it seems probable that 
the one head lay in the hollow formed by the neck of the other, and so 
rapidly followed it. If the feet presented, the case may be managed 
in the same manner as in Class A. 

Class D. — Monstrosities of Class D, in which the heads are united, 
the bodies being distinct, appear to be the most uncommon of all, and 
I can find the description of delivery in only 2 cases. One of these 
gave rise to great difficulty; the labor in the other was easy. AVe 
should scarcely anticipate much difficulty in the birth of monstei*s of 
this type ; for if the head presented and would not pass, we should 
naturally perform craniotomy; and if the bodies came first, the delivery 
of the monstrous head could readily be accomplished by perforation. 

The result to the mothers in all these cases seems to have been 
very favorable. There is only one in which the death of the mother 
is recorded; and although in many the result is not mentioned, we 
may fairly assume that recovery took place. 

Among difficulties in labor some of tlie most important are duo to 
morbid conditions of the fa^tus itself. 

Intra-uterine Hydrocephalus. — Of these the most common, as well 
as the most serious, is caused by intra-uterine hydrocephalus (^eiving 

[' The celebrated Carolina twins, born -Inly 11, 1S51, ami still livinix, wore brouixht 
into the world by the same naethod, bnt the mother, havinu: ;i larire pelvis. " had a brief 
and easy" delivery. The larger o( the two girls also came tii-st. as in the T/.oni case 
of 1701. These twins are now sixteen years older than the Hungarian sistei";? were at 
death, and will soon be thirty-eight years old. — Kn.] 



378 LABOR. 

rise to a collection of watery fluid within the cranium), by Avhich the 
dimensions of the child^s head are enormously increased and the due 
relations between it and the pelvic cavity entirely destroyed (Fig. 

Fortunately, this disease is of comparatively rare occurrence, for it is 
one of great gravity both as regards the mother and child. As regards 
the mother, the serious character of the complication is proved by the 

Fig. 130. 




Labor Impeded by Hydrocephalus. 

statistics of Dr. Keiller of Edinburgh, who found that out of 74 cases 
no less than 16 were accompanied by rupture of the uterus. The reason 
of the danger to which the mother is subjected is obvious. In some few 
cases, indeed, the head is so compressible that, provided the amount of 
contained fluid be small, it may be sufficiently diminished in size by the 
moulding to which it is subjected to admit of its being squeezed through 
the pelvis. In the majority of cases, however, the size of the head is 
too great for this to occur. The uterus therefore exhausts itself, and 
may even rupture, in the vain endeavor to overcome the obstacle, while 
the large and distended head presses firmly on the cervix, or on the 
pelvic tissues if the os be dilated, and all the evil effects of prolonged 
compression are apt to follow. 

The diagnosis of intra-uterine hydrocephalus is by no means so easy 
as the description in obstetric works would lead us to believe. It is 
true that the head is much larger and more rounded in its contour than 
the healthy foetal cranium, and also that the sutures and fontanelles are 
more wide and admit occasionally of fluctuation being perceived through 
them. Still, it is to be remembered that the head is always arrested 
above the brim, where it is consequently high up and difficult to reach, 
and where these peculiarities are made out with much difficulty. As a 
matter of fact, the true nature of the case is comparatively rarely dis- 



DYSTOCIA FROM FCETUS. 379 

covered before delivery; thus Chaussier^ found that in more than 
one-half of the cases he collected an erroneous diagnosis had been 
made. 

Whenever we meet with a case in which either the history of 
previous labor or a careful examination convinces us that there is no 
obstacle due to pelvic deformity, in which the pains are strong and 
forcing, but in which the head persistently refuses to engage in tlie brim, 
we may fairly surmise the existence of hydrocephalus. Nothing, how- 
ever, short of a careful examination under anaesthesia, the whole hand 
being passed into the vagina so as to explore the presenting part thor- 
oughly, will enable us to be quite sure of the existence of this compli- 
cation. Under these circumstances such a complete examination is not 
only justified, but imperative; and when it has been made the difficulties 
of diagnosis are lessened, for then we may readily make out the large 
round mass, softer and more compressible than the healthy head, the 
widely separated sutures, and the fluctuating fontanel les. 

In a considerable proportion of cases — as many, it is said, as 1 out of 
5 — the foetus presents by the breech. The diagnosis is then still more 
difficult; for the labor progresses easily until the shoulders are born, 
when the head is completely arrested, and refuses to pass with any 
amount of traction that is brought to bear on it. Even the most care- 
ful examination may not enable us to make out the cause of the delay, 
for the finger will impinge on the comparatively firm base of the skull, 
and may be unable to reach the distended portion of the cranium. At 
this time abdominal palpation might throw some light on the case, for, 
the uterus being tightly contracted round the head, we might be able 
to make out its unusual dimensions. The wasted and shrivelled appear- 
ance of the child's body which so often accompanies hydrocei)halus 
would also arouse suspicion as to the cause of delay. On the whole, 
such cases may be fairly assumed to be less dangerous to the mother 
than when the head presents, for in the latter the soft parts are apt to be 
subjected to prolonged pressure and contusion, while in the former delay 
does not commence till after the shoulders are born, and then the charac- 
ter of the obstacle would be sooner discovered and appropriate means 
earlier taken to overcome it. 

The treatment is simple, and consists in tajiping the head, so as 
to allow the cranial bones to collapse. There is the less objection to this 
course, since the disease almost necessarily precludes the hope of the 
child's surviving. The aspirator would draw off the fluid effectuallv, 
and would at least give the child a chance of life: and under certain 
circumstances the birth of a child who lives lor a short time only may 
be of extreme legal im])ortance. More generally the perforator will be 
used, and as soon as it has penetrated a gush of fluid will at once veritV 
the diagnosis. Schroeder recommends that after perforation turning 
should be performed, on account of the difficulty with which the flaccid 
head is propelled through tlu> pelvis. This seems a very imnecessary 
complication of an already sufficiently troublesome case. As a rule, 
when once the Huid has be(Mi evacuatcHl, the ]>ains Ihmuo- strono-, as thev 
generally are, no delay need be apprehended. Should the head not 

^ Gazdk )ucdicaU\ ISlM. 



380 LABOR. 

come down, the cephalotribe may be applied, which takes a firmer grasp 
than the forceps, and enables the head to be crushed to a very small size 
and readily extracted. 

AVhen the breech presents the head must be perforated through the 
occipital bone, and generally this may be accomplished behind the ear 
without much difficulty. In a case of Tarnier's the vertebral column 
was divided by a bistouiy and an elastic male catheter introduced into 
the vertebral canal, through which the intracranial fluid escaped, the 
labor being terminated spontaneously.^ In any case in which it is found 
difficult to reach the skull with the perforator this procedure should 
certainly be tried. 

Other forms of dropsical effusion may give rise to some difficulty, 
but by no means so serious. In a few rare cases the thorax has been so 
distended with fluid as to obstruct the passage of the child. Ascites is 
somew^hat more common, and occasionally the child's bladder is so dis- 
tended with urine as to prevent the birth of the body. The existence 
of any of these conditions is easily ascertained; for the head or breech, 
whichever happens to present, is delivered without difficult}^, and then 
the rest of the body is arrested. This will naturally cause the prac- 
titioner to make a careful exploration, when the cause of the delay 
will be detected. 

The treatment consists in the evacuation of the fluid by puncture. 
In the case of ascites this should always be done, if possible, by a fine 
trocar or aspirator, so as not to injure the child. This is all the more 
important since it is impossible to distinguish a distended bladder from 
ascites, and an opening of any size into that viscus might prove fatal, 
whereas aspiration would do little or no harm and would prove quite as 
efficacious. 

Foetal Tumors Obstructing Delivery. — Certain foetal tumore may 
occasion dystocia, such as malignant growths or tumors of the kidney, 
liver, or spleen. Cases of this kind are recorded in most obstetric 
works. Hydro-encephalocele or hydro-rachitis, depending on defective 
formation of the cranial or spinal bones, wdth the formation of a large 
protruding bag of fluid, is not very rare. The diagnosis of all such 
cases is somewhat obscure, nor is it possible to lay down any definite 
rules for their management, which must vary according to the particular 
exigencies. The tumors are rarely of sufficient size to prove formidable 
obstacles to delivery, and many of them are very compressible. This 
is specially the case with the spina bifida and similar cystic growths. 
Puncture — and in the more solid growths of the abdomen or thorax 
evisceration — may be required. 

Other deformities, such as the anencephalous foetus, or defective 
development of the thorax or abdominal parietes, with protrusion of 
the viscera, are not likely to cause difficulty, but they may much em- 
barrass the diagnosis by the strange and unusual presentation that is 
felt. If in any case of doubt a full and careful examination be under- 
taken, introducing the whole hand if necessary, no serious mistake is 
likely to be made. 

Dystocia from Excessive Development of the Foetus. — In addi- 

^ Hergott, Maladies fcetales qui peuvent faire obstacle a P accouchement, Paris, 1878. 



DYSTOCIA FROM FCETUS. 381 

tion to dystocia from morbid conditions of the foetus, difficulties may 
arise from its undue development, and especially from excessive size and 
advanced ossification of the skull. This last is especially likely to cause 
delay. Even the slight difference in size between the male and female 
head was found by Simpson to have an appreciable effect in increasing 
the difficulty of labor when the statistics of a large number of cases 
were taken into account ; for he proved beyond doubt that the difficul- 
ties and casualties of labor occurred in decidedly larger proportion in 
male than in female births. Other circumstances besides sex have an 
important effect on the size of the child. Thus, Duncan and Hecker 
have shown that it increases in proportion to the age of the mother and 
the frequency of the labors ; Avhile the size of the parents has no doubt 
also an important bearing on the subject. 

Although these influences modify the results of labor en masse, they 
have little or no practical bearing on any particular case, since it is 
impossible to estimate either the size of the head or the degree of its 
ossification until labor is advanced. 

Treatment. — When labor is retarded by undue ossification or large 
size of the head, the case must be treated on the same general princi- 
ples which guide us when the want of proportion is caused by pelvic 
contraction. Hence, if delay arise which the natural powers are insuf- 
ficient to overcome, it will seldom happen that the disproportion is too 
great for the forceps to overcome. If we fail to deliver by it, no 
resource is left but perforation. 

Large size of the body of the child is still more rarely a cause of 
difficulty, for if the head be born the compressible trunk will almost 
always follow. Still, a few authentic cases are on record in which it 
was found impossible to extract the foetus on account of the unusual 
bulk of its shoulders and thorax. Should the body remain firmly 
impacted after the birth of the head, it is easy to assist its delivery 
by traction on the axillae, by gently aiding the rotation of the shoulders 
into the antero-posterior diameter of the pelvic cavity, and, if neces- 
sary, by extracting the arms, so as to lessen the bulk of the part of the 
body contained in the pelvis. Hicks relates a case in which eviscera- 
tion was required for no other apparent reason than the enormous size 
of the body. The necessity for any such extreme measure must of 
course be of the greatest possible rarity ; and it is quite exceptional for 
difficulty from this source to be beyond the i)owors of nature to over- 
come. 



382 LABOR. 



CHAPTER XII. 

DEFORMITIES OF THE PELVIS. 

Deformities of the pelvis form one of the most important subjects 
of obstetric study, for from them arise some of the gravest difficukies 
and dangers connected vith parturition. A knowledge, therefore, of 
their causes and effects, and of the best mode of detecting them either 
during or before labor, is of paramount necessity ; but the subject is far 
from easy, and it has been rendered more difficult than it need be from 
over-anxiety on the part of obstetricians to force all varieties of pelvic 
deformities within the limits of their favorite classification. 

Difficulties of Classification. — !Many attempts in this direction 
have been made, some of which are based on the causes on which the 
deformities depend, others on the particular kind of deformity pro- 
duced. The changes of form, however, are so various and irregular, 
and similar or apparently similar causes so constantly produce different 
effects, that all such endeavors have been more or less unsuccessful. 
For example, we find that rickets (of all causes of pelvic deformity the 
most important) generally produces a narrowing of the conjugate diam- 
eter of the brim ; while the analogous disease, osteomalacia, occurring 
in adult life, generally produces a contraction of the transverse diame- 
ter, with approximation of the pubic bones and relative or actual elon- 
gation of the conjugate diameter. We might therefore be tempted to 
classify the results of these two diseases under separate heads did we 
not find that when rickets affects children who are running about and 
subject to mechanical influences similar to those acting upon patients 
suffering from osteomalacia, a form of pelvis is produced hardly distin- 
guishable from that met with in the latter disease, which by some authors 
is described as the pseudo-osteomalacic. 

On the whole, therefore, the most simple as well as the most scientific 
classification is that which takes as its basis the particular seat and nature 
of the deformity. Let us first glance at the most common causes. 

Causes of Pelvic Deformity. — The key to the particular shape 
assumed by a deformed pelvis will be found in a knowledge of the cir- 
cumstances which lead to its regular development and normal shape in 
a state of health. The changes produced may almost invariably be 
traced to the action of the same causes which produce a normal pelvis, 
but which under certain diseased conditions of the bones or articula- 
tions induce a more or less serious alteration in form. These have been 
already described in discussing the normal anatomy of the pelvis ; and 
it will be remembered that they are chiefly the weight of the body, 
transmitted to the iliac bones through the sacro-iliac joints, and counter- 
23ressure on these, acting through the acetabula. Sometimes they act in 
excess on bones which are healthy, but possibly smaller than usual, and 
the result may be the formation of certain abnormalities in the size of 



DEFORMITIES OF THE PELVIS. 383 

the various pelvic diameters. At other times they operate on bones 
which are softened and altered in texture by disease, and which there- 
fore yield to the pressure far more than healthy bones. 

Rickets and Osteomalacia. — The two diseases which chiefly ope- 
rate in causing deformity are rickets and osteomalacia. Into the essen- 
tial nature and symptomatology of these complaints it would be out of 
place to enter here : it may suffice to remind the reader that they are 
believed to be pathologically similar diseases, with the important prac- 
tical distinction that the former occurs in early life before the bones are 
completely ossified, and that the latter is a disease of adults producing 
softening in bones that have been hardened and developed. This dif- 
ference affords a ready explanation of the generally resulting varieties 
of pelvic deformity. 

Rickets commences very early in life — sometimes, it is believed, 
even in utero. It rarely produces softening of the entire bones, and 
only in case of very great severity of those parts of the bones that have 
been already ossified. The effects of the disease are principally appar- 
ent in the cartilaginous portions of the bones, in which osseous deposit 
has not yet taken place. The bones, therefore, are not subject to uni- 
form change, and this fact has an important influence in determining 
their shape. Rickety children also have imperfect muscular develop- 
ment : they do not run about in the same way as other children, they 
are often continuously in the recumbent or sitting posture, and thus the 
weight of the trunk is brought to bear, more than in a state of health, 
on the softened bones. For the same reason counter-pressure through 
the acetabula is absent or comparatively slight. When, however, the dis- 
ease occurs for the first time in children who are able to run about, the 
latter comes into operation and modifies the amount and nature of the 
deformity. It is to be observed that in rickety children the bones are 
not only altered in form from pressure, but are also imperfectly devel- 
oped, and this materially modifies the deformity. When ossific matter 
is deposited the bones become hard and cease to bend under external 
influences, and retain for ever the altered shape they have assumed. 

In osteomalacia, on the contrary, the already hardened bones 
become softened uniformly through all their textures, and thus the 
changes which are impressed upon them are much more regular and 
more easily predicated. It is, however, an infinitely less common cause 
of pelvic deformity than rickets, as is evidenced by the fact that in the 
Paris Maternity, in a period of sixteen years, 402 casesof deformity due 
to rickets occurred to 1 due to osteomalacia.^ 

Their Varying Frequency. — The frequency of both diseases varies 
greatly in different countries and under diflerent circumstances. Rick- 
ets is much more connnon amongst the poor of largo cities, whose chil- 
dren are ill-fed, badly-clothed, ke})t in a vitiated atmospliere, and sub- 
jected to unfavorable hygienic conditions. IVforniitios are therefore 
more common in them tlian in the more healthy children of the upper 
classes or of the rural population. The higher degrcn^s of deformity, 
necessitating the Ca^sarcan section or craniotomy, are in England of 
extreme rarity; while in certain districts on the Continent they seem to 
^ Stanesco, RcchcrcJu's ^'lini^pu\< i>ur les Ectrecissemcnts du Bas^in. 



384 LABOR. 

be so frequent that these ultimate resources of the obstetric art have to 
be constantly employed. 

In another class of cases the ordinary shape is modified by weight and 
counter-pressure operating on a pelvis in Avhich one or more of the 
articulations is ossified. In this way we have produced the ohliquely 
ovate pelvis of Naegele or the still more uncommon transversely con- 
tracted pelvis of Robert. 

Other Causes of Pelvic Deformity. — A certain number of deformed 
pelves cannot be referred to a modification of the ordinary develop- 
mental changes of the bones. Amongst these are the deformities result- 
ing from spondyl-olisthesis, or downward dislocation of the lower lum- 
bar vertebrae ; from displacements of the sacrum caused by curvatures 
of the spinal column^ producing the kyphotic and scoliotic pelves ; or 
from diseases of the pelvic bones themselves, such as tumors, malignant 
growths, and the like. 

The first class of deformed pelves to be considered is that in which 
the diameters are altered from the usual standard without any definite 
distortion to the bones ; and such are often mere congenital variations 
in size for which no definite explanation can be given. Of this class is 
the pelvis which is equally enlarged in all its diameters (pelvis oequabiH- 
terjusio major), which is of no obstetric consequence, except inasmuch 
as it may lead to precipitate labor and is not likely to be diagnosed 
during life. 

The corresponding diminution of all the pelvic diameters {pelvis 
cequabiliterjusto minor) may be met with in women who are apparently 
well formed in every respect, and whose external conformation and pre- 
vious history give no indication of the abnormality. Sometimes the 
diminution amounts to half an inch or more, and it can readily be 
understood that such a lessening in the capacity of the pelvis would give 
rise to serious difficulty in labor. Thus, in 3 cases recorded by Naegele 
a fatal result followed — in 2 after difficult instrumental delivery, and in 
the third after rupture of the uterus. The equally lessened pelvis, how- 
ever, is of great rarity. An unusually small pelvis may be met with in 
connection with general small size, as in dwarfs. It does not necessarily 
follow that because a woman is a dwarf the pelvis is too small for par- 
turition. On the contrary, many such women have borne children 
without difficulty. 

[We may be greatly deceived by the external characteristics of a large 
and tall woman as to the presumed development of her pelvis, and be 
led to credit her with diameters far beyond the actual measurements. 
In a lady above the average height, with large hips and now weighing 
over two hundred pounds, I found a vagina which the index finger 
entered with difficulty, and a pelvis so small that it is doubtful if she 
could be delivered of a living foetus much over seven months. She 
bore one child at maturity, which was delivered after its death with a 
crushed head, at the end of three days' labor and after long and power- 
ful traction by compressing forceps. She has a true justo minor pelvis. 
—Ed.] 

In some cases a pelvis retains its infantile characteristics after puberty 
(Fig. 131). The normal development of the pelvis has been interfered 



DEFORMITIES OF THE PELVIS. 385 

with, possibly from premature ossification of the different portions of 
the innominate bones or from arrest of their growtli from a weakly or 
rachitic constitution. The measurements of these pelves are not always 
below the normal standard ; they may continue to grow, although they 
have not developed. The proportionate measurements of the various 

Fig. 131. 




Adult Pelvis retaining its Infantile Type. 

diameters will then be as in the infant ; and the antero-posterior diam- 
eter may be longer or as long as the transverse, the ischia comparatively 
near each other, and the pubic arch narrow. Such a form of pelvis will 
interfere with the mechanism of delivery and unusual difficulty in labor 
will be experienced. Difficulties from a similar cause may be expected 
in very young girls. Here, however, there is reason to hope that as age 
advances the pelvis will develop and subsequent labors be more easy. 

The masculine or funnel-shaped pelvis owes its name to its approx- 
imation to the type of the male pelvis. The bones are thicker and 
stouter than usual, the conjugate diameter of the brim longer, and the 
whole cavity rendered deeper and narrower at its lower part by the 
nearness of the ischial tuberosities. It is generally met with in strong, 
muscular women following laborious occupations, and Dr. Barnes, from 
his experience in the Royal Maternity Charity, says that it chiefly 
occurs in weavers in the neighborhood of Bethnal Green, Avho spend 
most of their time in the sitting ])osture. '^ The cause of this form o{ 
pelvis seems to be an advanced condition of ossitication in a pelvis 
which would otherwise have been infant He, brought about by the devel- 
opment of unusual muscularity, corresponding to the laborious employ- 
ment of the individual." The dilficulties in labor will naturally be mot 
Avith toward the outlet, where the funnel shape oi' the cavity is most 
apparent. 

Dimiuution of the antero-posterior diameter [tlatfenc(^ pelrifi) is most 
frequently limited to the brim, and is by far the most eonnnon variety 
of pelvic deformity. In its slighter degrees it is not necessiirily depend- 

25 



386 



LABOR. 



eut on rickets, although when more marked it almost invariably is so. 
AVhen unconnected with rickets it probably can be traced to some inju- 
rious influence before the bones have ossified, such as increased pressure 
of the trunk, from carrying weights in early childhood, and the like. 
By this means the sacrum is unduly depressed and projects forward, so 
as to slightly narrow the conjugate diameter. 

Mode of Production in Rickets. — When caused by rickets the 
amount of the contraction varies greatly, sometimes being very slight, 
sometimes sufficient to prevent the passage of the child altogether, and 
necessitate craniotomy or the Csesarean section. The sacrum, softened 
by the disease, is pressed vertically downward by the weight of the 
body, its descent being partially resisted by the already ossified portions 
of the bone, so that the result is a downward and forward movement of 
the promontory. The upper portion of the sacral cavity is thus directed 
more backward ; but, as the apex of the bone is drawn forward by the 
attachment of the perineal muscles to the coccyx and by the sacro-ischi- 
atic ligaments, a sharp curve of its lower part in a forward direction is 
established. The horizontal rami of the pubes are also flattened, while 
the ischia are more widely separated than in a normal pelvis, thus pro- 
ducing a greater width of the . pubic arch, while the acetabula are 
turned forward. 

The depression of the sacral promontory would tend to produce 
strong traction through the sacro-iliac ligaments on the posterior end of 

Fig. 132. 




Scolio-rachitic Pelvis. 
(From a specimen in the IMuseum of St. Bartholomew's Hospital.) 



the sacro-cotyloid beams, and thus induce expansion of the iliac bones 
and consequent increase of the transverse diameter of the brim. So an 
unusual length of the transverse diameter is very often described as 



DEFORMITIES OF THE PELVIS. 387 

accompanying this deformity, but probably it is not so often apparent 
as might otherwise be expected, on account of the imperfect develop- 
ment of the bones generally accompanying rickets; and Barnes' says 
• that in the parts of London where deformities are most rife any enlarge- 
ment of the transverse diameter is exceedingly rare. 

Frequently the sacrum is not only depressed, but displaced more or 
less to one side, most generally to the left, thus interfering with the reg- 
ular shape of the deformed brim. This is often the result of a lateral 
flexion of the spinal column, depending on the rachitic diathesis, and 
Avhen well marked is known as the Hcolio-rachitic pelvis (Fig. 132j, in 
which one side of the pelvis, that corresponding to the direction of the 
pelvic curve, is asymmetrical and contracted, the ilio-pectineal line being 
sharply curved inward about the site of the sacro-iliac synchondrosis, 
the symphysis pubis being displaced toward the opposite side. A 
somewhat similar but much less marked, unilateral asymmetry may 
exist in cases of scoliosis [^] unconnected with rickets, but rarely to a 
sufficient degree to interfere materially with labor. 

In most cases of this kind the cavity of the pelvis is not diminished 
in size, and is often even more than usually wide. The constant 
pressure on the ischia which the sitting posture of the child entails 
tends to force them apart and also to widen the pubic arch. Consider- 

FiG. 133. 




Rickety Pelvis, with backward depression of sympliysis pubis. 

able advantage results from this in cases in Avhich we have to perform 
obstetric operations, as it gives plenty of room for manipulation. 

^ Lectures on Obst. Operations, p. 280. 

[■■'Although liunchbacks frequently have well-formed pelves, it is not uncommon to 
find a deformed spine associated with an asynunetrical pelvis or even a nuicli con- 
tracted one. Spinal distortion from caries, especially in the lumbar re<jion, is thus 
associated, and tlie pelvic deformity will be increased if there has been coxaliiia, 
either double or single, or if from any cause one leg should be shorter than "the 
other. In the records of the Porro operation we tiuil under "the cause of ditH- 
culty," " pseud o-osteomalac in,'' '' lumbo-dorsal ki/phosis,'' '' k-i/pho-svoliosis," etc. I^iuio- 
osteomulacia is the result of rickets in a walking child, "the form of pelvis being 
changed mecluuiically, as in osteomalacia. Liimho-dorsal h/phosis mav or mav no^ 
give rise to tiie kyphotic pelvis, as nnich will depend upon the extent of vertebral 
caries. Scoliosis is apt to result from rickets, and may be associated with lordosis. 

Scoliosis, from aKohot;, crooked— a distortion i>f the spine to one siile. 

lAvdosis, from lopdoc, curv,ed— applied i^articularlv to the forward bendin>: o( the 
spine. 

Ki/phosis, from KVipuaic, gibbous, arched, or vaulted— a hump or backward curvature 
of the spine. — Ed. | 



388 



LABOR. 



Fig. 134. 




Figure-of-eight Deformity. — In a few exceptional cases the narrow- 
ing of the conjugate diameter is increased by a backw^ard depression 
of the symphysis j^ubiSj which gives the pelvic brim a sort of figure-of- 
eight shape (Fig. 133). The most reasonable explanation of this pecu- 
liarity seems to be that it is the result of the muscular contraction of the 
recti muscles at their point of attachment, when the centre of gravity of 
the body is thrown backward on account of the projection of the sacral 

promontory. Sometimes also the 
antero-posterior diameter of the 
cavity is unusually lessened by the 
disappearance of the vertical curva- 
ture of the sacrum, which instead 
of forming a distinct cavity i& 
nearly flat (Fig. 134). 

Spondyl-olisthesis. — In a few 
rare cases, to which attention was 
first called in 1853 by Kilian of 
Bonn, a very formidable narrow- 
ing of the conjugate diameter of 
the pelvic brim is produced by a 
downward displacement of the 
fourth and fifth lumbar vertebrae, 

forward, 
or, if not actually dislocated, at 
least separated from their several articulations to a sufficient extent 
to encroach very seriously on the dimensions of the pelvic inlet. 

This condition is known as spondyl-olis- 
thesis (Fig. 135). 

The effect of this is sufficiently obvi- 
ous, for the projection of the lumbar 
vertebrae prevents the passage of the 
child. To such an extent is obstruction 
thus produced that in the majority of 
the recorded cases the Csesarean section 
was necessary. The true conjugate diam- 
eter, that between the promontory of the 
sacrum and the symphysis pubis, is in- 
creased rather than diminished ; but for 
all practical purposes the condition is sim- 
ilar to extreme narrow^ing of the conjugate 
from rickets, for the bodies of the displaced 
vertebrae project into and obstruct the pel- 
vic brim. 

The cause of this deformity seems to be 

different in different cases. In some it seems 

to have been congenital, and in others to 

have depended on some antecedent disease 

of the bones, such as tuberculosis or scrofula, producing inflammation 

and softening of the connection between the last lumbar vertebra and 

the sacrum, thus permitting downward displacement of the bones. 



Flatness of Sacrum, with narrowing of pelvic which become dislocatcd 
cavity. 



Fig. 135. 




Pelvis Deformed by Spondyl-oli 
thesis 

(After Kilian.) 



DEFORMITIES OF THE PELVIS. 



389 



Fig. 136. 



Lambl believed that it generally followed spiim bifida, which had 
become partially cured, but which had produced deformity of the 
vertebrae and favored their dislocation. Brodhurst/ on the other 
hand, thinks that it most probably depends on rachitic inflammation 
and softening of the osseous and ligamentous structures, and that it is 
not a dislocation in the strict sense of the word. This condition has 
recently been made the subject of special study by Dr. Franz L. 
Neugebauer,^ who believes that the forward displacement is never the 
result of antecedent disease of the bones, but depends either on congen- 
ital want of development of the vertebral arches or on traumatism, such 
•as fracture of the articular processes, which allows the weight of the 
trunk to displace the body of the last lumbar vertebra forward, either 
partially or entirely. 

[We are indebted to Kilian of Germany for the first careful investi- 
gation of the true character of spondyl-olisthetic deformity, although 
the credit of initial mention is due 
to Rokitansky of Austria, who wrote 
in 1839, antedating the monograph 
of the former (1853) by fourteen 
years. No special mention is made 
of this peculiar lordosis by Roki- 
tansky in his Ifanual of Patholog- 
ical Anatomy in 1844, but in his 
Lekrhuch (1855) it is given, with 
due credit, to Kilian. During the 
thirty-three years that have passed 
since Kilian prepared his paper from 
observations made upon three pelves 
which had been obtained from sub- 
jects in whom the C?esareau section 
had proved fatal, one of them after 
a second operation, there have ap- 
peared numerous monographs and 
descriptions of cases, much the most 
valuable and extensive of which are 
those by Dr. Franz Ludwig Neuge- 
bauer of Warsaw and Dr. A. Swedelin of St. Petersburg, the latter of 
whom furnishes the bibliography of the subject. These valuable ])apei's 
cover 223 and 40 pages respectively of the Archiv fur Gymihologiey 
Berlin, vols, xix., xx., xxi., xxii., and xxv., for 1882-85. 

The most frequent origin of spondyl-olisthetic deformity appears to 
lie in an incomplete ossification of the'last Uuubar vertebra," wherebv its 
anterior and jwsterior portions are rendered liable to separate under 
the superincumbent weight of t\\Q body. Hence the subjects o\^ the 
slipping are frequently stout, heavy women. This was marked Iv 
the case in the woman who came under the care ot' Prof .laiues 




[Spondyl-olisthesis. (After Ncngebauer.)] 



Blake of San Francisco.'^ This patient was 



•ied 



at titi«.vn 



1 Oh^t. Trans., 1865, vol. vi. p. 97. 

^ Oouiribittioii d la Pafluntcuic du Pi(,<iii)i vide par Ic GlL^t^cvicnt irrtcbral, Vm[<: \SS-i. 

l^ IW. Med. and Sun/. Journ., Feb., 1867.] 



390 LABOR. 

years of age, at wliich time she weighed 101 pounds, but increased 
to 199 pounds by the time her first child was born. Her first 
and second labors were tedious, but the children were born alive; 
she aborted of another foetus at four months, and later was delivered 
at maturity of four others, all dead, the conjugate space in the seventh 
labor being computed at 3J inches. This labor was so difficult that 
it was decided, in the event of another pregnancy, to bring on labor 
prematurely. She became pregnant for the eighth time at the age of 
twenty-six, when she weighed 220 pounds. Labor was induced in the 
seventh montli, but the foetus was lost, as it weighed nearly six pounds 
and the lumbo-pubic space was reduced to 3 inches. This woman is* 
said to have undergone the change in her vertebrae without pain or sign 
of ill-health, and to have retained a remarkable activity for her weight. 
After her eighth delivery she was up in six days and down stairs in ten. 
The history of this case would indicate that the deforming process must 
have been slowly progressing during more than ten years. 

In contrast with this painless case in a multipara we have the oppo- 
site in a nullipara, reported by Dr. Olshausen, formerly of Halle. The 
disease commenced in his patient when a girl of eighteen with severe 
pains in the sacrum and hips, as in malacosteon. She had not had 
rickets in childhood, had enjoyed good health up to this time, and was 
quite straight. As her disease progressed she found on awaking one 
morning that she could not straighten her spine, and was forced to walk 
with her body bent forward. She was put under medical treatment at 
the surgical clinic; had no fever, and in time ceased to suffer, and wa& 
discharged. Becoming pregnant at the age of twenty-four. Dr. 
Olshausen delivered her in 1863 by the C^esarean section: the child 
lived, but she was lost on the fourth day by peritonitis. The lumbo- 
pubic diameter was found to measure 3 inches, and the line of the con- 
jugate struck tlie lower margin of the third lumbar vertebra. — Ed.] 

Spondyl-olizeraa. — A somewhat analogous deformity has been de- 
scribed by Hergott ^ under the name of spondyl-olizema. In this the 
bodies of the lower lumbar vertebrae having been destroyed by caries, the 
upper lumbar vertebrae sink downward and forward, so as to obstruct 
the pelvic inlet and prevent the engagement of the foetus. It thus 
differs from spondyl-olisthesis, in which there is dislocation, but not 
destruction, of the bodies of the lower lumbar vertebrae. 

Deformity from Osteomalacia. — The most marked examples of 
narrowing of both oblique diameters depend on osteomalacia. In this 
disease, as has already been remarked, the bones are uniformly softened, 
and the alterations in form are further influenced by the fact that the 
disease commences after union of the separate portions of the ossa in- 
nominata has been completely effected. The amount of deformity in 
the worst cases is very great, and frequently renders delivery impossible 
without the Caesarean section. Sometimes the softening of the bones 
proves of service in delivery, by admitting of the dilatation of the con- 
tracted pelvic diameter by the pressure of the presenting part or even 
by the hand. Some curious cases are on record in which the deformity 
was so great as to apparently require the Caesarean section, but in 

^ Arch, de Tocoloyie, 1877, p. 65. 



DEFORMITIES OF THE PELVIS. 



391 



which the softened bones eventually yielded sufficiently to render this 
unnecessary. 

The weight of the body depresses the sacrum in a vertical direction, 
and at the same time compresses its component parts together, so as to 
approximate the base and apex of the bone and narrow the conjugate 
diameter of the brim by causing the })roniontory to en(.Toach upon it. 
The most characteristic changes are produced by the pushing inward 
of the walls of the pelvis at the cotyloid cavities, in consequence of 
pressure exerted at these points through the femora. The eifect of 

Fig. 137. 




Osteomalacic Pelvis, [i] 



this is to diminish both oblique diameters, giving the brim somewhat 
the shape of a trefoil or an ace of clubs. The sides of the pubes are 



Fig. 138. 




Kxtronio Dogroc of (">sti>onial;u'ic Dofonuity. 

at the same time a[)])roximarc(l, niul may Ixvomo almost ]KU-allol, :ind 
the true conjugate may be even lengthened (Fig. lo7\ The tnborosi- 

[' This form is kiunvn as roMmte or boakoiL The true oonjuiiato moasiuv is no 
iiulifation of tlio oxtont of doformity. A ravhiiio pelvis of this form in front is teruu\i 
a pscu(io-mal(U'ic one. — Ki>.] 



392 LABOR. 

ties of the ischia are also compressed together, with the rest of the 
lateral pelvic wall, so that the outlet is greatly deformed as well as 
the brim (Fig. 138). 

[Osteoraalacia not an Araerican Disease. — lu not one of the 183 
Csesarean operations of the United States was the operation performed 
for this kind of deformity. The disease has sometimes been met with in 
foreigners who have been delivered by the forceps or craniotomy. But 
few American accoucheurs have ever seen a case, and I have not heard of 
an extreme rostrate pelvis having been met with in our country. — Ed.] 
Obliquely-contracted Pelvis. — That form of deformity in which 
one oblique diameter only is lessened has received considerable attention 
from having been made the subject of special study by Xaegele, and is 
generally known as the ohliquely-contraded j^elvis (Fig. 139). It is 

a condition that is very rarely met 
Fig. 139. with, although it is interesting from 

an obstetric point of view, as throw- 
ing considerable light on the mode in 
which the natural development of the 
pelvis is aifected. It is difficult to diag- 
nose, inasmuch as there is no apparent 
external deformity, and probably it has 
never, in fact, been detected before de- 
livery. It has a very serious influence 
on labor : Litzmann found that out of 
28 cases of this deformity, 22 died in 
their labors and 5 more in subsequent 
^^^'^'(ifcr^DuncS?)''''''''- deliveries. The prognosis, therefore, is 

very formidable, and renders a know- 
ledge of this distortion, rare though it be, of importance. 

Its essential characteristic is flattening and want of development of 
one side of the pelvis, associated with ankylosis of the corresponding 
sacro-iliac synchondrosis. The latter is probably always present, and it 
seems to be most generally a congenital malformation. The lateral half 
of the sacrum on the same side, and the entire innominate bone, are 
much atrophied. The promontory of the sacrum is directed toward the 
diseased side and the symphysis pubis is pushed toward the healthy side. 
The main agent in the production of this deformity is the absence of 
the sacro-iliac joint, which prevents the proper lateral expansion of the 
pelvic brim on that side, and allows the counter-pressure through the 
femur to push in the atrophied os innominatum to a much greater 
extent than usual. The chief diminution in the length of the pelvic 
diameter is between the ilio-pectineal eminence of the affected side and 
the healthy sacro-iliac joint, while the oblique diameter between the 
ankylosed joint and the healthy os innominatum is of normal length. 
[Coxalgia in young subjects will produce a form of obliquely-con- 
tracted pelvis, the ilium being stunted in growth, as well as the cor- 
responding extremity, and the superior strait rendered small and 
D-shaped. Cases of this deformity have been four times operated upon 
in the United States by the Csesarean section. — Ed.] 

Narrowing- of the Transverse Diameter. — Transverse contraction 




DEFORMITmS OF THE PELVIS. 



393 



Fig. 140. 



of the pelvic brim is very much less common than narrowing of the 
conjugate diameter. It most frequently depends on backward curva- 
ture of the lower parts of the spinal column in consequence of disease 
of the vertebrse. This form of deformed pelvis is generally known as 
the kyphotic (Fig. 140). The effect of the spinal curvature is to drag 
the promontory of the sac- 
rum backward, so that it is 
high up and out of reach. 
By this means the antero- 
posterior diameter of the 
brim is increased, while the 
transverse is lessened; the 
relative proportion between 
the two is thus reversed. 
While the upper portion 
of the sacrum is displaced 
backward, its lower end is 
projected forward, so that 
the antero-posterior diame- 
ters of the cavity and out- 
let are considerably dimin- 
ished. The ischial tuberosi- 
ties are also nearer to each 
other and the pubic arch is 
narrowed. Obstruction to 
delivery will be chiefly met 
with at the lower parts and 
outlet of the pelvic cavity; 
for, although the transverse 
diameter of the brim is nar- 
ro\ved, there is generally suf- 
ficient space for the passage 
of the head. 

Robert's Pelvis. — An- 
other form of transversely-contracted pelvis is known as Bobcrfs pelvis 
(Fig. 141), having been first discovered by Kobert of Coblentz. It 
is in fact a double obliquely-contracted 
pelvis, depending on ankylosis of both 
sacro-iliac joints, and consequent defec- 
tive development of the innominate 
bones. The sha])e of the pelvic brim 
is markedly oblong, and the sides of 
the pelvis are more or less paraUel 
with each other. The outlet is also 
much contracted transversely. The 
amount of obstruction is very great, 
so that, according to Schroodor, out of 
7 well-authenticated eases, the Cesa- 
rean section was rccpiired in (>. 

Deformity from Old-standing *'''^''"'^i^;;[;!;:"*;^raor'{iu;;Su;::"^''''^ 




Kyphotic Pelvis. 
(From a specimen in the Museum of St. Bartholomew's Hospital.) 




394 



LABOR. 



Fig. 142. 



Hip-joint Disease. — Another cause of transverse deformity occasion- 
ally met with is luxation of the head of the femur depending on old- 
standing joint disease. The head of the femur in this case presses on 
the innominate bone at the site of dislocation, and the result is that the 
iliac fossa on the affected side, or both if the accident happens on both 
sides, is pushed inward, the transverse diameter of the brim being less- 
ened. The tuberosity of the ischium is, however, projected outward, so 
that the outlet of the pelvis is increased rather than diminished. 

Deformity from Tumors, Fractures, etc. — Obstruction of the 
pelvic cavity from exostoses or other forms of tumors growing from 
the bones is of great rarity (Fig. 142). It may, however, produce 

very serious dystocia. Several curious 
examples are collected in Mr. Wood's 
article on the pelvis, in some of which 
the obstruction was so great as to ne- 
cessitate the Csesarean section. Some 
of these growths were true exostoses, 
and, according to stadfeldt,^ these are 
commonly found in pelves that are 
otherwise contracted ; others, osteo- 
sarcomatous tumors attached to the 
pelvic bones, most generally the upper 
part of the sacrum ; and others were 
malignant. In some cases spiculse of 
bone have developed about the linea 
ilio-pectinea or other parts of the pel- 
vis, which may not be sufficient to 
produce obstruction, but which may 
injure the uterus, or even the foetai 
head, when they are pressed upon 
them. Irregular projections may 
also arise from the callus of old 
All such cases defy classification, and 
differ so greatly in their extent and in their effect on labor that no rules 
can be laid down for them, and each must be treated on its own merits. 
The effects of pelvic contractions on labor vary, of course, 
greatly with the amount and nature of the deformity, but they must 
always give rise to anxiety, and in the graver degrees they produce the 
most' serious difficulties we have to contend with in the whole range of 
obstetrics. 

In the lesser degrees, in which the proportion between the presenting 
part and the pelvis is only slightly altered, we may observe little abnor- 
mal beyond a greater intensity of the pains and some protraction of the 
labor. It is generally observed that the uterine contractions are strong 
and forcible in cases of this kind, probably because of the increased 
resistance they have to contend against ; and this is obviously a desir- 
able and conservative occurrence, which may of itself suffice to overcome 
the difficulty. The first stage, however, is not unfrequently prolonged, 
and the pains are ineffective, for the head does not readily engage in the 
1 Obstetrical Journal, 1879-80, vol. vii. p. 201. 




Bony Growth from Sacrum obstructing 
the I'elvic Cavity. 



fractures of the pelvic bones. 



DEFORMITIES OF THE PELVIS. .39o 

brim, the uterus is more mobile than in ordinary labors, and it probably 
acts at a disadvantage. 

Risks to the Mother. — In the more serious eases the mother is sub- 
jected to many risks directly proportionate to the amount of obstruction 
and the length of the labor. The long-continued and excessive uterine 
action, produced by the vain endeavors to push the child through the 
contracted pelvic canal, the more or less prolonged contusion and injury 
to which the maternal soft parts are necessarily sul)jected (not unfre- 
quently ending in inflammation and sloughing with all its attendant 
dangers), and the direct injury which may be inflicted by the measures 
we are compelled to adojjt for aiding delivery (such as the forceps, 
turning, craniotomy, or Csesarean section), all tend ta make the progno- 
sis a matter of grave anxiety. [The Csesarean operation has been per- 
formed 9 times in the United States in cases of pelvic exostosis, with 4 
recoveries. One woman was operated upon three times and died from the 
third operation : 4 of the 9 children were saved. Of the fatal cases, 3 
were in labor three days, 1 two days and 1 had been in convulsions for 
twenty-four hours. Of the 4 that recovered, 1 was in labor " a few 
hours ;'^ 1, twelve hours; 1, twenty-four hours; and 1, thirty-eight 
hours. — Ed.] 

Risks to the Child. — Nor are the dangers less to the child, and a 
very large proportion of stillbirths will always be met Avith. The infan- 
tile mortality may be traced to a variety of causes, the most important 
being the protraction of the labor and the continuous pressure to which 
the presenting part is subjected. For this reason, even in cases in which 
the contraction is so slight that the labor is terminated by the natural 
powers, it has been estimated that one out of every five children is still- 
born ; and as the deformity increases in amount, so of course does the 
prognosis to the child become more unfavorable. 

Prolapse of the umbilical cord is of very frequent occurrence in 
cases of pelvic deformity, the tendency to this accident being traceable 
to the fact of the head not entering and occupying the upper strait of 
the pelvis as in ordinary labors, and thus leaving a space through ^vhich 
the cord may descend. So frequently is this complication met with in 
pelvic deformity that Stanesco found it had happened as often as 59 
times in 414 labors; and when the dangers of prolapsed funis are added 
to those of ])r()tracted labors, it is hardly a matter of sur})rise that the 
occurrence should, under such circumstances, almost always prove fatal 
to the child. 

The head of the child is also liable to injiuy of a more or less grave 
character from the compression to which it is subjected, especially by 
the promontory of the sacrum. Independently of the transient effects 
of undue ])ressure (temporary alteration of the shape v>[' the bones and 
bruising of the seal})), there is olVen met with a more serious de]>rtssion 
of the bones of the skull, produced by the sacral promontory. This is 
most marked in cases in which the head has been t'oreiblv drnggeil pasc 
the projecting bone by the forcei>s or after turning. The amount o{^ 
depression varies with the degr(HM>i' coutrnction ; but sometimes, were 
it not for the yielding of the bones of the tcvtal skull in this way, deUv- 
ery without lessening the size of the head by pertbraiion would be 



396 LABOR. 

impossible. Such depressions are found at the spot immediately oppo- 
site the promontory, generally at the side of the skull near the junction 
of the frontal and parietal bones. Sometimes there is a slight perma- 
nent mark, but more often the depression disappears in a few days. The 
prognosis to the child is, however, grave when the contraction has been 
sufficient to indent the skull, for it has been found that 50 per cent, of 
the children thus marked died either immediately or shortly after 
labor.^ 

Course of Labor. — The means which nature takes to overcome 
these difficulties are well worthy of study, and there are certain peculi- 
arities in the meclianism of delivery when pelvic deformities exist 
which it is of importance to understand, as they guide us in determining 
the proper treatment to adopt. 

Frequency of Malpresentation. — Malpresentations of the foetus are 
of much more frequent occurrence than in ordinary labors ; partly 
because the head does not engage readily in the brim, but, remaining 
free above it, is apt to be pushed away by the uterine contractions, and 
partly because of the frequent alteration of the axis of the uterine 
tumor. The pendulous condition of the abdomen in cases of pelvic 
deformity is often very obvious, so that the fundus is sometimes almost 
in a line with the cervix, and thus transverse or other abnormal positions 
are very frequently met with. It is to be noted, however, that we can- 
not regard breech presentations as so unfavorable as in ordinary labors, 
for the pressure from the contracted pelvis is less likely to be injurious 
when applied to the body than to the head of the child ; and, indeed, as 
we shall presently see, the artificial production of these presentations is 
often advisable as a matter of choice. 

Mechanism of Delivery in Head Presentations. — The mode in 
which the head passes naturally through a contracted pelvis is in some 
respects different from the ordinary mechanism of delivery in head 
presentations, and has been carefully worked out by Spiegelberg and 
other German obstetricians. 

The means which nature adopts to overcome the difficulty are differ- 
ent in cases in which there is a marked narrowing of the conjugate 
diameter of the brim and in those in which there is a generally-con- 
tracted pelvis. 

a. In Contracted Brim. — In the former and more common 
deformity the head lies at the brim with its long occipito-fron- 
tal diameter in the transverse diameter of the pelvis, and, as 
both parietal bones cannot enter the contracted brim, it lies witli 
one parietal bone on a much lower level than the other, in the 
large majority of cases that nearest the pubes being most depressed, 
so that the sagittal suture is felt high up near the promontory of the 
sacrum (Fig. 143). As labor advances, if the contraction is not too 
great to be insuperable, the anterior fontanelle comes much more within 
reach than in ordinary labor, while at the same time the occipital por- 
tion of the head is shoved to the side of the pelvis, so that its narrow 
bitemporal diameter engages in the contracted conjugate. At this stage, 
on examination, it will be found — supposing we have to do with a case 

^ Schroeder, op. cit., p. 256. 



DEFORMITIES OF THE PELVIS. 



397 



Fig. H3. 




Head passing through the Inlet 
in Flat Pelvis. (After Parvin.) 



in which the occiput points to the left side in the pelvis — that tlie ante- 
rior fontanelle is lower than tlie posterior and to the right^ that tiie 
bitemporal diameter of the head is engaged in the conjugate diameter 
of the brim (as the smallest diameter of the skull there is manifest ad- 
vantage in this), and that the biparietal di- 
ameter and the largest portion of the head 
points to the left side. The sagittal suture 
will be felt running across in the transverse 
diameter of the brim, but nearer to the sa- 
crum, the head being placed obliquely. As 
the head is forced down by the uterine con- 
tractions, the parietal bone, which is resting 
on the promontory, is pushed against it, so 
that the sagittal suture is forced more into 
the true transverse diameter of the pelvic 
brim, and approaches nearer to the pubes. 
The next step is the depression of the head, 
the occiput undergoing a sort of rotation on 
its transverse axis, so that it reaches a plane 
below the brim. When this is accomplished 
the rest of the head readily passes the ob- 
struction. The forehead now meets with 
the resistance of the pelvic walls, the posterior fontanelle descends to a 
lower level, and, as the cavity of the pelvis in cases of antero-posterior 
contraction of the brim is generally of normal dimensions, the rest of 
the labor is terminated in the usual way. 

b. In Generally-contracted Pelvis. — In the generally-contracted 
pelvis the head enters the brim with the posterior fontanelle lowest, 
and it is after it has engaged in it that the resistance to its progress 
becomes manifest. The result is, therefore, an exaggeration of what 
is met Avith in ordinary cases. The resistance to the anterior or longer 
arm of the lever is greater than that to the occipital or shorter, and 
therefore the flexion of the head becomes very marked (Fig. 144). 

The posterior fontanelle is consequently un- 
usually depressed, and the anterior quite out 
of reach. So the head is forced down as a 
wedge, and its further progress must depend 
upon the amount of contraction. If this be 
not too great, the anterior fontanelle eventu- 
ally descends, and delivery is completeil in 
the usual way. Should the contraction be 
too nnich to permit of this, tlie head Ixvomes 
jammed in the pelvis and diminution of its 
size may be essential. 

In eases of deformity of the conjugate dia^ 
meter, combined with general contraction o^ 
the pelvis, the mechanism partakes of the 
peculiarities of both these classes to a greater 
or less extent, in proportion to tlu^ preponder- 
ance of one or other species of detormiiy. 



Fig. 144. 




Marked Flexion of the Head en- 
tering a (lenerally-eontracted 
Pelvis. (After Pnr'vin.) 



398 LABOR. 

Diagnosis. — It rarely happens that deformities of the pelvis, except 
of the gravest kind, are suspected before labor has actually commenced, 
and therefore we are not often called upon to give an opinion as to the 
condition of the pelvis before delivery. Should we be, there are various 
circumstances which may aid us in arriving at a correct conclusion. 
Prominent among them is the history of the patient in childhood. If 
she is known to have suffered from rickets in early life, more especially 
if the disease has left evident traces in deformities of the limbs or in a 
dwarfed and stunted growth or in curvature of the spine, there will be 
strong presumptive evidence of pelvic deformity ; a markedly pendu- 
lous state of the abdomen may also tend to confirm the suspicion. 
Xothing short of a careful examination of the pelvis itself will, how- 
ever, clear up the point with certainty ; and even by this means to 
estimate the precise degree of deformity with accuracy requires con- 
siderable skill and practice. The ingenuity of practitioners has been 
much exercised — it might perhaps be justly said wasted — in the inven- 
tion of various more or less complicated pelvimeters for aiding us in 
obtaining the desired object. It is, ho^^'ever, pretty generally admitted 
by all accoucheurs that the hand forms the best and most reliable instru- 
ment for this purpose — at any rate, as regards the interior of the pelvis ; 
although a pair of callipers, such as Baudelocque's well-known instru- 
ment, is essential for accurately determining the external measurements. 
The objections to all internal pelvimeters, even those most simple in 
their construction, are their cost and complexity and the impossibility 
of using them without pain or injury to the patient. 

It was formerly thought that by measuring the distance between the 
spinous processes of the sacrum and the symphysis pubis, and subtract- 
ing from it what we judge to be the thickness of the bones and soft 
parts, we might arrive at an approximate estimate of the measurement 
of the conjugate diameter of the pelvic brim. It is now admitted that 
this method can never be depended on, and that, taken by itself, it is 
practically useless. A change in the relative length of our external 
measurements of the pelvis is, however, often of great value in show- 
ing the existence of deformity internally, although not in judging of 
its amount. The measurements which are used for this purpose are 
between the anterior suj^erior spines of the ilia and between the centres 
of their crests, averaging respectively 10 and 11 inches. According to 
Spiegelberg, these measurements may give one of three results : 

1. Both may be less than they ought to be, but the relation of one to 
the other remains unchanged. 

2. That between the crests is not, or is at most very little, diminished, 
but that between the spines is increased. 

3. Both are diminished, but at the same time their mutual relation 
is not normal, the distance between the spines being as long as, if not 
longer than, that between the crests. 

Xo. 1 denotes a uniformly-contracted pelvis ; Xo. 2, a pelvis simply 
contracted in the conjugate diameter of the brim, and not otherwise 
deformed ; Xo. 3, a pelvis with narrowed conjugate and also uniformly 
contracted, as in the severe type of rachitic deformity. If, however, 
both these measurements are of averao:e leno^th and the distance 



DEFORMITIES OF THE PELVIS. 



399 



between the crests is about one inch greater than between the spines, 
the pelvis is normal. 

Besides the above, some information may be obtained by the measure- 
ment of the external conjugate diameter, which averages 7f inches. 
This may be taken by placing one point of the callipers in the de])res- 
sion below the spine of the last lumbar vertebra, the other at the centre 
of the upper edge of the symphysis pubis. If the measurement be 
distinctly below the average — not more, for example, than 6.3 in. — ^ve 
may conclude that there is a narrowing of the antero-posterior diameter 
of the brim, the extent of which we must endeavor to ascertain by 
other means. 

For the purpose of making these measurements Baudelocque's com- 
pas (T^pakseur can be used, or Dr. Lazarewitch's elegant universal pel- 
vimeter, which can be adopted also for internal pelvimetry ; but in the 
absence of these special contrivances an ordinary pair of callipers, such 
as are used by carpenters, can be made to answer the desired object. 

These external measurements must be corroborated by the internal, 
chiefly of the antero-posterior diameter, by which alone we can estimate 
the amount of the deformity. We endeavor to find, in the first place, 
the length of the inclined conjugate between the lower edge of the sym- 
physis pubis and the promontory of the sacrum, which averages about 
half an inch more than the true conjugate. This is best done by 
placing the patient on her back, with the hips w^ell raised. The index 
finger of the right hand is then introduced into the vagina, and the 
perineum is pressed steadily back- 
ward, so as to overcome the resist- 
ance it offers. If the tip of the 
finger can reach the promontory of 
the sacrum, its radial side is raised 
so as to touch the lower edge of 
the pubes. A mark is made with 
the nail of the index of the left 
hand on that part of the examin- 
ing finger wdiich rests under the 
symphysis, and then the distance 
from this to the tip of the finger, 
less half an inch, may be taken 
to indicate the measurement of the 
true conjugate of the brim. Vari- 
ous pelvimeters have been devised 
to make the same measurements, 
such as Lundey Earle's, Lazare- 
witch's (which is similar in prin- 
ciple), and Van Huevel's. The 
best and simplest, I think, is that 
invented by Dr. Greenhnlgli (Fig. 
145). It consists of a movable rod 
metal which passes around the palm 
dista' ^ ' ' ' " * 



Fig. 14r 




Croenhalgh's Pelviiuotor 
to the flexible 



attaehea ro tiie 
of the examinino- 



hand. 



ot 
the 



edge of 



end of the rod is a curved portion, which 
the index finmH*. The examination is 



oanc 
At 
passes over the radia 
made in the usual wav 



400 LABOR. 

and when the point of the finger is resting on the promontory of the 
sacrum, tlie rod is withdrawn until it is arrested by the posterior surface 
of the symphysis, the exact measurement of the inclined conjugate being 
then read off the scale. 

It is to be remembered that this procedure is useless in the slighter 
degrees of contraction in which the promontory of the sacrum cannot 
be easily reached. Dr. Ramsbotham proposed to measure the conjugate 
by spreading out the index and middle fingers internally, the tip of one 
resting on the promontory, the other behind the symphysis pubis, and 
then drawing them in the same position and measuring the distance 
between them. This manoeuyre I belieye to be impracticable. 

AYheneyerj in actual labor, we wish to ascertain the condition of the 
pelyis accurately, the patient shoukl be anaesthetized, and the whole 
hand introduced into the yagina (which could not otherwise be done 
without causing great pain), and the proportions of the pelvis and the 
relations of the head to it thoroughly explored; and, if what has been 
said as to the mechanism of deliyery in these cases be borne in mind, 
this may aid us in determining the kind of deformity existing. In this 
way contractions about the outlet of the pelyis can also be pretty gener- 
ally made out. 

The obliquely-contracted pelyis cannot be determined by any of these 
methods, but certain external measurements, as Kaegele has pointed out, 
will readily enable us to recognize its existence. It will be found that 
measurements which in the healthy pelyis ought to be equal are unequal 
in the obliquely-distorted pelyis. The points of measurement are 
chiefly : (1) From the tuberosity of the ischium on one side to the 
posterior superior spine of the ilium on the other ; (2) from the ante- 
rior superior iliac spine on one side to the posterior superior on the 
opposite; (3) from the trochanter major of one side to the posterior 
superior iliac spine on the other; (4) from the lower edge of the sym- 
physis pubis to the posterior superior iliac spine on either side; (5) from 
the spinous process of the last lumbar vertebra to the anterior superior 
spine of the ilium on either side. 

If these measurements differ from each other by half an inch to an 
inch, the existence of an obliquely-deformed pelvis may be safely diag- 
nosed. The diagnosis can be corroborated by placing the j^atient in the 
erect position and letting fall two plumb-lines, one from the spines of 
the sacrum, the other from the symphysis pubis. In a healthy pelvis 
these will fall in the same plane, but in the oblique pelvis the anterior 
line will deviate consideraby toward the unafPected side. 

Treatment. — The proper management of labor in contracted pelvis 
is, even up to this time, one of the most vexed questions in midwifery, 
notwithstanding the immense amount of discussion to which it has given 
rise; and the varying opinions of accoucheurs of equal experience afford 
a strong proof of the difficulties surrounding the subject. This remark 
applies, of course, only to the lesser degree of deformity, in which the 
birth of a living child is not hopeless. When the antero-posterior 
diameter of the brim measures from 2f to 3 inches, it is universally 
admitted that the destruction of the child is inevitable, unless the pelvis 
be so small as to necessitate the performance of the Csesarean section. 



DEFORMITIES OF THE PELVIS. 401 

But when it is between 3 inches and the normal measurement the com- 
parative merits of the forceps, turning, and the induction of premature 
labor form a fruitful theme for discussion. With one class of accouch- 
eurs the forceps is chiefly advocated, and turning admitted as an occa- 
sional resource when it has failed ; and this indeed, speaking broadly, 
may be said to have been the general view held in England. More 
recently we find German authorities of eminence, such as Schroeder and 
Spiegelberg, giving turning the chief place, and condemning the forceps 
altogether in contracted pelves, or at least restricting its use within very 
narrow limits. More strangely still, we find, of late, that the induction 
of premature labor, on the origination and extension of which British 
accoucheurs have always prided themselves, is placed without the pale 
and spoken of as injurious and useless in reference to pelvic deformities. 
To see our way clearly amongst so many conflicting opinions is by no 
means an easy task, and perhaps we may best aid in its accomplishment 
by considering separately the three operations in so far as they bear on 
this subject, and pointing out briefly what can be said for and against 
each of them. 

The Forceps. — In England and in France it is pretty generally 
admitted that in the slighter degrees of contraction the most reliable 
means of aiding the patient is by the forceps. It should be remembered 
that the operation under such circumstances is always much more serious 
than in ordinary labors simply delayed from uterine inertia, when there 
is ample room and the head is in the cavity of the pelvis ; for the blades 
have to be passed up very high, often when the head is more or less 
movable above the brim, and much more traction is likely to be required. 
For these reasons artificial assistance when pelvic deformity is suspected 
is not to be lightly or hurriedly resorted to. Nor, fortunately, is it 
always necessary, for if the pains be sufficiently strong and the con- 
traction not too great to prevent the head engaging at all, af^-er a lapse 
of time it will become so moulded in the brim as to pass even a con- 
siderable obstruction. In all cases, therefore, sufficient time must be 
given for this ; and if no suspicious symptoms exist on the part of the 
mother — no elevation of temperature, dryness of the vagina, rapid jndse, 
and the like, and the foetal heart-sounds continue to be normal — labor 
may be allowed to go on for some hours after the rupture of the mem- 
branes, so as to give nature a chance of completing the delivery. AVhen 
this seems hopeless the intervention of art is called for. 

The forceps is generally considered to be a|)plicable in all degrees of 
contraction from the standard measurement down to about 3 J inches in 
the conjugate of the brim. There can be no doubt that in such cases 
traction with the forceps often enables us to etfect delivery when the 
natural efforts have proved insufficient, and holds out a very fair hope 
of saving the child. Out of 17 cases in which the high-forceps opera- 
tion was resorted to for pelvic deformity, reported by Stanesco, in lo, 
living children were born. If the length of the labor and the long- 
continued compression to which the child has been subjected be borne in 
mind, this result nuist be considered very favorable. 

AVhat are the objections which have been brought against tiie opera- 
tion ? These have been principally made by Schroeder and other Gor- 

26 



402 LABOR. 

man Avriters. They are, chiefly, tlie difficulty of passing the instrument, 
the risk of injuring the maternal structures, and the supposition that, as 
the blades must seize the head by the forehead and occiput, their com- 
pressive action will diminish its longitudinal and increase its transverse 
diameter (which is op^^osed to the contracted part of the brim), and so 
enlarge the head just where it ought to be smallest. There is little 
doubt that these writers much exaggerate the compressive power of 
the forceps. Certainly, with the forms generally used in England any 
disadvantage likely to accrue from this is more than counterbalanced 
by the traction of the head ; and the fact that minor degrees of 
obstruction can be thus overcome with safety both to the mother and 
child is abundantly proved by the numberless cases in which the for- 
ceps has been used. 

It is very likely that the forceps does not act equally well in all cases. 
When the head is loose above the brim ; when the contraction is chiefly 
limited to the antero-posterior diameter, and there is abundance of room 
at the sides of the pelvis for the occiput to occupy after version; and 
when, as is usual in these cases, the anterior fontanelle is depressed and 
the head lies transversely across the brim, — it is probable that turning 
may be the safer operation for the mother, and the easier performed. 
AVhen, on the other hand, the head has engaged in the brim and 
has become more or less impacted, it is obvious that version could 
not be performed without pushing it back, which may be neither easy 
nor safe. In the generally-contracted pelvis, in which the head enters 
in an exaggerated state of flexion and lies obliquely, the posterior 
fontanelle being much depressed, the forceps is more suitable. 

Mechanical Advantage of Turning- in Certain Cases. — The 
special reasons why version sometimes succeeds when the forceps 
fails, or why it may be elected from the first as a matter of choice, 
have been by no one better pointed out than by Sir James Simpson. 
Although the operation was performed by many of the older obstetri- 

FiG. 146. Fig. 147. 



Section of Foetal Cranium, showing its Showing the Greater Breadth of the 

conical form Biparietal Diameter of the Foetal 

Cranium, (After Simpson.) 

cians, its revival in modern times and the clear enunciation of its princi- 
ples can undoubtedly be traced to his writings. He points out that the 
head of a child is shaped like a cone its narrowest portion the base of the 



DEFORMITIES OF THE PELVIS. 403 

cranium (Fig. 146, h b), measuring, on an average, from J to f of an 
inch less than the broadest portion (Fig, 146, a a) — viz. the biparietal 
diameter. In ordinary head presentations the latter part of the head 
has to pass first; but if the feet are brought down, the narrow aj)ex of 
the cranial cone is brought first into apposition with the contracted brim, 
and can be more easily drawn through than the broader base can be 
pushed through by the uterine contractions. Nor is this the only advan- 
tage, for after turning the narrower bitemporal diameter (Fig. 147, b b) 
— which measures, on an average, half an inch less than the biparietal 
(Fig. 147, a a) — is brought into contact with the contracted conjugate, 
while the broader biparietal lies in the comparatively wide space at the 
side of the pelvis (Fig. 148). These mechanical considerations are 

Fig. 148. 




Showing the Greater Space for the Biparietal Diameter at the side of the pelvis in certain cases 
of deformity. (After Simpson.) 

sufficiently obvious, and fully explain the success which has often 
attended the performance of the operation. 

It is generally admitted that it may be possible, for the reasons just 
mentioned, to deliver a living child by turning through a }^elvis con- 
tracted beyond tlie point which would permit of a living child being- 
extracted by the forceps. Many obstetricians believe that it is possible 
to deliver a living child by turning in a pelvis contracted even to the 
extent of 2| inches in the conjugate diameter. Barnes maintains that, 
although an unusually compressible head may be drawn through a pel- 
vis contracted to 3 inches, the chance of the child being born alive under 
such circumstances must necessarily be small, and that from 3J inches 
to the normal size must be taken as the proper limits of the operation. 

That delivery is often possible by turning after the forcejis and the 
natural powers have failed, and when no other resource is left but the 
destruction of the child, nuist, I think, be admitted by all, for the 
records of obstetrics are full of such cases. To take one example only : 
Dr. l)raxton Hicks ^ records 4 cases in which the forceps was tried 
unsuccessfully, in all of which version was used, 3 of the children being- 
born alive. Here are the lives of three childriMi rescued from ilestruc- 
tion within a short period in the practice of one man : and a fact like 
this would of itself be ample justification of the attempt to deliver by 
turning when the child was known to be alive and inher means had 
failed. The ])ossibility that craniotomy mav still be rec|iiired is no 

^ Oinis llof^pital Iu'port.<, 1S70. 



404 LABOR. 

argil iiieut against the operation ; for although perforation of the after- 
coming head is certainly not so easy as perforation of a presenting head, 
it is not so much more difficult as to justify the neglect of an experi- 
ment by which it may possibly be altogether avoided. 

The original choice of turning is a more difficult question to decide. 
The most generally received opinion in the j^resent day among scientific 
obstetricians is that in the simply flattened pelvis, with an antero-poste- 
rior diameter of not less than 2 J inches, turning is the preferable ope- 
ration. In ever}^ case of doubt it is desirable thoroughly to anaesthetize 
the patient and make a careful examination with the whole hand in the 
vagina. If we find the sagittal suture lying transverselv, one parietal 
bone on a lower line than the other/ and if both fontauelles are easily 
within reach, and' some space exists at the sides of the pelvis beside the 
forehead and occiput, then turning is the procedure most likely to suc- 
ceed, and the descent of the head after version can be very materially 
assisted by strong pressure applied from above by an assistant, as has 
been well pointed out by Goodell.^ If, on the other hand, the anterior 
fontanelle is high up and out of reach, the head being distinctly flexed, 
we have to do with a generally-contracted pelvis and the forceps is the 
preferable operation. 

When the contraction is below 3 inches in the conjugate, or when the 
forceps and turning have failed, no resource is left but the destruction 
of the foetus or the Csesarean section. 

The Induction of Premature Labor. — The induction of premature 
labor as a means of avoiding the risks of delivery at term, and of possi- 
bly sa\dng the life of the child, must now be studied. The established 
rule in England is, that in all cases of pelvic deformit}^ the existence 
of which has been ascertained either by the experience of former labors 
or by accurate examination of the pelvis, labor should be induced pre- 
vious to the full period, so that the smaller and more compressible head 
of the premature foetus may pass where that of the foetus at term could 
not. The gain is a double one — partly the lessened risk to the mother, 
and partly the chance of saving the child's life. 

The practice is so thoroughly recognized as a conservative and judici- 
ous one that it might be deemed unnecessaiy to argue in its favor, were 
it not that some eminent authorities have of late years tried to show that 
it is better and safer to the mother to leave the labor to come on at term, 
and that the risk to the child is so great in artificially induced labor 
as to lead to the conclusion that the operations should be altogether 
abandoned, except, perhaps, in the extreme distortion in which the 
Ccesarean section might otherwise be necessary. Prominent amongst 
those who hold these views are Spiegelberg and Litzmann, and they have 
been supported in a modified form by Matthews Duncan. Spiegelberg"^ 
tries to show, by a collection of cases from various sources, that the 
results of induced labor in contracted pelvis are much more unfavorable 
than when the cases are left to nature — that in the latter the mortalit}" 
of the mothers is 6.6 per cent, and of the children 28,7 per cent., 
♦vhereas in the former the maternal deaths are 15 per cent, and the 

^ Ainer. Journ. of Obstet., 1875-76, vol. viii. p. 193. 

• Arch./. Gyn., 1870, Bd. i. S., 1 : '* Ueber den Werth der kiintsliclien Friibgeburt.'^ 



DEFORMITIES OF THE PELVIS. 405 

iDfantile 66.9 per cent. Litzmann^ arrives at not very dissimilar re- 
sults — namely, 6.9 per cent, of the mothers and 20.3 per cent, of the chil- 
dren in contracted pelves at term, and 14.7 per cent, of the mothers and 
55.8 per cent, of the children in artificially induced premature labor. 

If these statistics were reliable, inasmuch as they show a very decided 
risk to the mother there might be great force in the argument that it 
would be better to leave the cases to run the chance of delivery at 
term. It is, however, very questionable whether they can })e 
taken, in themselves, as being sufficient to settle the question. The fal- 
lacy of determining such points by a mass of heterogeneous cases, col- 
lected together without a careful sifting of their histories, has over and 
over again been pointed out ; and it would be easy enough to meet them 
by an equal catalogue of cases in which the maternal mortality is almost 
nil. The results of the practice of many authorities are given in 
Churchill's work, where we find, for example, that out of 46 cases of 
Merriman's, not one proved fatal. The same fortunate result happened 
in 62 cases of Ramsbotham's. His conclusion is that " there is undoubt- 
edly some risk incurred by the mother, but not more than by accidental 
premature labor ; " and this conclusion as regards the mother is that 
which has long ago been arrived at by the majority of British obstetri- 
cians, who undoubtedly have more experience of the operation than 
that of any other nation. With regard to the child, even if the Ger- 
man statistics be taken as reliable, they would hardly be accepted as 
oontraindicating the operation, inasmuch as it is intended to save the 
mother from the dangers of the more serious labor at term, and in many 
cases to give at least a chance to the child, whose life would otherwise 
be certainly sacrificed. The result, moreover, must depend to a great 
extent on the method of operation adopted, for many of the plans of 
inducing labor recommended are certainly, in themselves, not devoid of 
danger both to the mother and the child. It may, I think, be admit- 
ted, as Duncan contends, that the operation has been more often per- 
formed than is absolutely necessary, and that the higher degrees of 
pelvic contraction are much more uncommon than has been supposed to 
be the case. That is a very valid reason for insisting on a careful and 
accurate diagnosis, but not for rejecting an operation which has so long 
been an established and favorite resource. 







Inches. 


Lines. 




WJien tlie sncro 


-pubic diameter 


■ is 2 and 


6 or 7, induce labor 


at 30th week. 


" 


u 


2 " 


8 " 9, 


" 31st " 


a 


(( 


2 " 


10 '' 11, 


" 32d 


a 


(( 


8 " 


a 


" 33d " 


u 


« 


3 •' 


1, 


" 33d " 


« 


<( 


3 " 


2 or 3, 


" 34th " 


« 


t( 


3 " 


4 " 5, 


" 3oth " 


a 


(I 


3 " 


5 '' i\ 


'* 3t>th " 



When the induction of labor has been determined on, the jn'ociso 
period at which it shoidd be resorted to becomes a question for anxious 
consideration, since the .longer it is delayed the greater, oi' course, are 
the dangers for the child. ^lany tables have been constructed to guide 

^ Arch. f. Oyn., 1873, Bd. ii. 8. 109 : " Ueber den Worth dor kiinstliohon FriihcobMn." 



406 LABOR. 

us on this point, which are not. on the whole, of so much service as 
they might appear to be, on account of the difficulty of determining 
with mmute accuracy the amount of contraction. The ])receding table, 
however, ^\■hich is drawn up by Kiwisch, may serve for a guide in 
settling this question. 

In cases of moderate deformity, when labor-pains have been induced, 
the further progress of the case may be left to nature ; but in more 
marked cases, as in those below 3 inches, it will often be found neces- 
sary to assist delivery by turning or by the forceps, the former being 
here especially useful, on account of the extreme pliability of the head 
and the facility- with which it may be drawn through the contracted 
brim. By thus combining the two operations it may be quite possible 
to secure the birth of a living child even in pelves very considerably 
deformed. 

Production of Abortion in Extreme Deformity. — AVhen the con- 
traction is so great as to necessitate the induction of the labor before 
the sixth month — or, in other words, before the child has reached a 
viable age — it would be preferable to resort to a very early production 
of abortion. The operation is then indicated, not for the sake of the 
child, but to save the mother from the deadly risk to which she would 
otherwise be subjected. As in these cases the mother alone is concerned, 
the operation should be performed as soon as we have positively deter- 
mined the existence of pregnancy. Xo object can be gained by waiting 
until the development of the child is advanced to any extent, and the 
less the fcetus is developed the less will be the pain and risks the mother 
has to undergo. There is no amount of deformity, however great, in 
which we could not succeed in bringing on miscarriage by some of the 
numerous means at our disposal ; and in spite of Dr. Eadford's objec- 
tions, who maintains that the obstetrician is not justified in sacrificing 
the life of a human being more than once when the mother knows 
that she cannot give birth to a viable child, there are few practitioners 
who would not deem it their duty to spare the mother the terrible 
dangers of the C?esarean section. 

[This opinion, by reason of remarkable successes during the last four 
years, has much less weight than it was entitled to a few years ago. 
The views of anti-Csesareanists in England are largely due to want 
of success at home ; and this want of success will continue until the 
operation is undertaken with greater promptness and with a confidence 
based upon continental opinions and results. We are now in this 
country adopting German rather than British views upon gastro-hys- 
terotomy, and as a re>fult, especially in our cities and maternity hos- 
pitals, are largely diminishing the proportion of deaths. Prof. ^Vm. 
Goodell showed his confidence in asepsis and the conservative method 
recently, by operating in a general hospital before a class of five hundred 
students : the woman did well and the child lived. The case was one 
of cancer, which proved fatal from sudden hemorrhage on the twenty- 
sixth day ; after the wotinds produced by the section had entirely healed, 
the cancerous ulceration having opened an important blood-vessel. The 
last five Csesarean operations in the city of Philadelphia have all been 
successful (April, 1888, to May, 1889,mclusive).— Ed.] 



HEMORRHAGE BEFORE fJELlVERY. 407 



CHAPTER XIII. 

HEMORRHAGE BEFORE DELIVERY: PLACENTA PREVIA. 

The hemorrhages which are the result of an abnormal situation of 
the placenta, partially or entirely, over the internal os uteri liave formed 
a most fruitful theme for discussion. The explanation of the abnormal 
placental site, the sources of the blood, and the causes of its escape, the 
means adopted by nature for its arrest, and the proper treatment, have, 
each and all of them, ])een the subject of endless controversies which 
are not yet by any means settled. It must be admitted, too, that the 
extreme importance of the subject amply justifies the attention which 
has been paid to it ; for there is no obstetric complication more apt to 
produce sudden and alarming effects, and none requiring more prompt 
and scientific treatment. 

Definition. — By placenta prmvia we mean the insertion of the pla- 
centa at the lower segment of the uterine cavity, so that a portion of 
it is situated, wholly or partially, over the internal os uteri. In the 
former case there is complete or central placental presentation, in the 
latter an incomplete or marginal presentation. 

Causes. — The causes of this abnormal placental site are not fully 
understood. It was supposed by Tyler Smith to depend on the ovule 
not having been impregnated until it had reached the lower part of 
the uterine cavity. Cazeaux suggests that the uterine mucous mem- 
brane is less swollen and turgid than when impregnation occurs at the 
more ordinary place, and that therefore it offers less obstruction to the 
descent of the ovule to the lower part of the uterine cavity. An abnor- 
mal size or unusual shape of the uterine cavity may also favor the 
descent of the impregnated ovule; the former probably ex])lains the 
fact that placenta pro3via more generally occurs in women who have 
already borne children. Miiller believes tliat it results from uterine 
contractions occurring shortly after conception, which force the ovum 
down to the lower part of the uterine cavity. . These are merely inter- 
esting speculations having no practical value, the fact being undoubted 
that in a not inconsiderable number of cases — estimated by Jolmson 
and Sinclair as 1 out of 573 — the ])lacenta is grafted partially or 
entirely over the uterine orifice, although it is now generally admitted 
that the ])lacenta is never attached to any ]X)rtion of the tHM'vix itsolt'. 
History. — Placenta pran^a was not inikmnvn to tlu^ older writers, 
who believed that the placenta had originally been situated at the 
fundus, from which it had accidentally fallen to the lower \x\yX of the 
uterus. Portal, F^evret, Roederer, and especially the British author 
Kigby, Avere among those whose observations tended to improve the 
state of obstetrical knowledge as to its real ntiture. To Higbv we owe 
the term ^'unavoidable hemorrhage" as a synonym tor placenta pra^\ ia. 
and as distino'uishino; hemorrhauv from this source tVom that rcstiltiuix 



408 LABOR. 

from separation of the placenta at its more usual position, termed by 
him, in contradistinction, " accidental hemorrhage." These means, 
adopted by most ^yriters on the subject, are obviously misleading, as 
they assume an essential distinction in the etiology of the hemorrhage 
in the two classes of cases which is not always warranted. 

It is of the utmost importance to a right understanding of the nature 
and treatment of placenta pr^evia that we should fully understand the 
source of the hemorrhage and the manner of its production ; but we 
shall be able to discuss this subject better after a description of the 
symptoms. 

Symptoms. — Although the placenta must occupy its unusual site 
from the earliest period of its formation, it rarely gives rise to appreci- 
able symptoms before the last three months of utero-gestation. It is far 
from unlikely, however, that such an abnormal situation of the placenta 
may produce abortion in the earlier months, the site of its attachment 
passing unobserved. 

The earliest symptom which causes suspicion is the sudden occurrence 
of hemorrhage without any appreciable cause. The amount of blood 
lost varies considerably. In some cases the first hemorrhage is com- 
paratively slight, and is soon spontaneously arrested ; but if the case 
be left to itself the flow after a lapse of time — it may be a few days 
or it may be weeks — again commences in the same unexpected way, 
and each successive hemorrhage is more profuse. The losses show 
themselves at diiferent periods. They rarely begin before the end of 
the sixth month, more often nearer the full period, and sometimes not 
until labor has actually commenced. The hemorrhage is said, but 
this is doubtful, to often coincide with what would have been a men- 
strual period, possibly on account of the physiological congestion of 
the uterine organs then present. Should the first loss not show itself 
until at or near the full time, it may be tremendous, and a few moments 
may suffice to place the patient's life in jeopardy. Indeed, it may be 
safely accepted as an axiom, that once hemorrhage has occurred the 
patient is never safe ; for excessive losses may occur at any moment 
without warning and when assistance is not at hand. It often hap- 
pens that premature labor comes on after one or more hemorrhages. 

In any case of placenta praevia, when labor has commenced, whether 
premature or at the full. time, the hemorrhage may become excessive, 
and with each pain fresh portions of placenta may be detached and fresh 
vessels torn and left open. Under these circumstances the blood often 
escapes in greater quantity Avith each successive pain, and diminishes in 
the interval. This has long been looked upon as a diagnostic mark by 
which we can distinguish between the so-called '^ unavoidable " and 
^' accidental '' hemorrhage, in the latter the flow being arrested during 
the pains. The distinction, liowever, is altogether fallacious. The tend- 
ency of uterine contraction in placenta prsevia, as in all other forms of 
uterine hemorrhage, is to constrict the vessels from which the blood 
escapes, and so to lessen the flow. The apparently increased flow dur- 
ing the pains depends on the pains forcing out blood which has already 
escaped from the vessels. In one way, up to a certain point, the pains 
do fiivor hemorrhage by detaching fresh portions of placenta ; but the 



HEMORRHAGE BEFORE DELIVERY. 409 

actual loss takes place chiefly during the intervals, and not during the 
continuance of contraction. 

On vaginal examination, if the os be sufficiently open to admit the 
finger — which it generally is on account of the relaxation produced by 
the loss of blood — we shall almost always be able to feel some porti(m 
of presenting placenta. If it be a central implantation, we shall find 
the aperture of the cervix entirely covered by a thick, boggy mass, 
which is to be distinguished from a coagulum by its consistence and by 
its not breaking down under the pressure of the finger. Through the 
placental mass we may feel the presenting part of the foetus, but not as 
distinctly as when there is no intervening substance. In partial placen- 
tal presentation the bag of membranes, and above it the head or other 
presentations, will be found to occupy a ])art of the circle of the os, the 
rest being covered by the edge of the placenta. In marginal presenta- 
tions we may only be able to make out the thickened edge of the after- 
birth projecting at the rim of the os. If the cervix be high and the 
gestation not advanced to term, these points may not be easy to make 
out on account of the difficulty of reaching the cervix ; and, as accurate 
diagnosis is of the utmost importance, it is proper to introduce two fin- 
gers, or even the whole hand, so as thoroughly to explore the condition 
of the parts. The lower portion of the uterine ovoid may be observed 
to be more than usually thick and fleshy ; and Gendrin has pointed out 
that ballottement cannot be made out. The accuracy of our diagnosis 
may be confirmed in doubtful cases by finding that the placental bruit 
is heard over the lower part of the uterine tumor. 

Dr. Wallace ^ has suggested that vaginal auscultation may be service- 
able in diagnosis, and states that by means of a curved wooden stetho- 
scope the placental bruit may be heard with startling distinctness. This 
is, however, a manoeuvre that can hardly be generally carried out in- 
actual practice. 

It is now generally admitted by authorities that the immediate source 
of the hemorrhage is the lacerated utero-placental vessels. Only a few 
years ago Sir James Simpson advocated, with his usual energv, the 
theory sustained by his predecessor. Dr. Hamilton, that the chief if not 
the only source of hemorrhage was the detaciied portion of the placenta 
itself. He argued that the blood flowed from the poi'tion of the pla- 
centa which was still adherent into that which was se])arated, and 
escaped from the surface of the latter ; and on this supposition he based 
his practice of entirely separating the placenta, having observed that in 
many cases in which the after-birth liad been expelled before the chiUl 
the hemorrhage had ceased. The fiict of the cessation of the hemor- 
rhage when this occurs is not doubled ; but Simpson's exj^lanation is 
contested by most modern writers, prominent among whom is Ixu'nos, 
wlio has devoted mu(?h study to the elucidation t>l' the subjec^t. lie 
points out that the stoppage of the hemorrhage is not due to the sei>a ra- 
tion of the placenta, but to th(^ pnreding or accompanying contraction 
of the uterus, which seals up the bleeding vessels, just as it tloes in other 
forms of hemorrhage. ' The site of the loss was actuallv domonstratiHl 
by the late V>r. ]\[ack(Mizie in a series oi^ experiments, in which ho par- 

^ Edin. Mid. Joarii., vol. IST'J To. v. ['17. 



410 LABOB. 

tially detached the placenta in pregnant bitches, and found that the 
blood flowed from the walls of the uterus, and not from the detached 
surface of the placenta. The arrangement of the large venous sinuses, 
opening as they do on the uterine mucous membrane, favors the escape 
of blood when they are torn across ; and it is from them, possiblv to 
some extent also from the uterine arteries, that the blood comes, just as 
in post-partum hemorrhage, when the whole instead of a part of the 
placental site is bared. 

Various explanations have been given of the causes of the hemor- 
rhage. For long it was supposed to depend on the gradual expansion 
of the cervix during the latter months of pregnancy, which separated 
the abnormally placed placenta. It has been seen, however, that this 
shortening of the cervix is apparent only, and that the cervical canal is 
not taken up into the uterine cavity during gestation, or, at all events, 
only during the last '\veek or so. This, therefore, cannot be admitted 
as an explanation of placental separation. Jacquemier proposed another 
theory, which has been adopted by Cazeaux. He maintains that during 
the first six months of utero-gestation the superior portion of the uterus 
is more especially developed, as shown by the pyriform shape of the 
fundus during the time, and that, as the placenta is usually attached in 
that situation and then attains its maximum of development, its rela- 
tions to its attachments are undisturbed. During the last three months 
of pregnancy, on the contrary, the lower segment of the uterus develops 
more than the upper, while the placenta remains nearly stationary in 
size ; the inevitable result being a loss of proportion between the cervix 
and the placenta, and the detachment of the latter. There are various 
objections which can be brought against this theory, the most important 
being that there is no evidence at all to show that the lower segment of 
the utertis does expand more in proportion than the upper during the 
latter months of pregnancy. Barnes' theory is based on the supposition, 
that the loss of relation between the uterus and placenta is caused by 
excess of growth on the part of the placenta itself over that of the cervix, 
which is not adapted for its attachment. The placenta, on this hypothe- 
sis, grows away from the site of its attachment, and hemorrhage results. 
It will be observed that neither this theory nor that proptounded by 
Jacquemier is readily reconcilable with the fact that hemorrhage fre- 
quently does not begin until labor has commenced at term. Inasmuch 
as the loss of relation between the placenta and its attachments, which 
they both presuppose, must exist in every case of placenta prsevia, hem- 
orrhage should always occur during some part of the last three months of 
preo'uaucv. ^Matthews Duncan " has recently investio:ated the whole sub- 
ject at length, and maintains that the hemorrhages are accidental, not 
unavoidable, being due to causes precisely similar to those which give 
rise to the occasional hemorrhages when the placenta is normally j^laced. 
The abnormal situation of the placenta of course renders these causes 
more apt to operate, but in their action he believes them to be precisely 
similar to those of accidental hemorrhage, properly so called. Separa- 
tion of the placenta from expansion of the cervix he believes to be the 

' Edin. Med. Journ., vol. 1873-74, pp. 3S5, 520; and Brit. Jled. Journ., 1873, vol. ii. 
pp. 499, 597, 625. 



HEMORRHAGE BEFORE DELIVERY. 411 

cause of hemorrhage after labor has begun, and then it may strictly be 
called unavoidable, but hemorrhage is comparatively seldom so pro- 
duced during the continuance of pregnancy. " There are/' says Duncan, 
" four ways in which this kind of hemorrhage may occur : 

^^1. By the rupture of a utero-placental vessel at or about the inter- 
nal OS uteri. 

" 2. By the rupture of a marginal utero-placental sinus within the 
area of spontaneous premature detachment, when the placenta is inserted 
not centrally or covering the internal os, but with a margin at or near 
the internal os. 

^^3. By a partial separation of the placenta from accidental causes, 
such as a jerk or falL 

" 4. By a partial separation of the placenta, the consequence of 
uterine pains producing a small amount of dilatation of the internal 
OS. Such cases may be otherwise described as instances of miscarriage 
commencing, but arrested at a very early stage.'' 

I see no reason to doubt the possibility of hemorrhage being due, in 
many cases, to the first three causes, and in its production it would 
strictly resemble accidental hemorrhage. The fourth heading refers 
the hemorrhage to partial separation in consequence of commencing 
dilatation of the cervix, but it explains the dilatation by the supposi- 
tion of commencing miscarriage. This latter hypothesis seems to' be 
as needless as those which presuppose a want of relation between the 
placenta and its attachments. We know that, quite independently of 
commencing miscarriage, uterine contractions are constantly occurring 
during the continuance of pregnancy. There is no reason to suppose 
that these contractions do not affect the cervical as well as the fundal 
portions of the uterus ; and in cases in which the placenta is situated 
partially or entirely over the os, one or more stronger contractions 
than usual may at any moment produce laceration of the placental 
attachments in that neighborhood. 

Pathological Chang-es in the Placenta. — A careful examination 
of the placenta may show pathological changes at the site of separa- 
tion, such as have been described by Gendrin, Simpsmi, and other 
writers. They probably consist of thromboses in the placental cotyl- 
edons and eifused blood-clots, variously altered and decolorized aci^ord- 
ing to the lapse of time since separation took ])lace. Changes occur in 
the portion of the phicenta overlying the os uteri, whether separation has 
occurred or not. There may be atro})hy of the placental structure in 
this situation, as well as changes of form, such as complete or partial 
separation in two lobes, the junction of which overlies the (^s uteri. ^ 

The history of delivery, if left to nature, is specially win*ihy K^i' 
study, as guiding to })roper rules of treatment. It sometimes happens, 
when the pains are very strong and the delivery rapid, that labor is 
comph^ted without any hemorrhage oi' consequence. *' Although." 
says Cazeaux, " hemorrhage is usually considered to be inevitable 
muler such circumstances, yet it may not apfvar even during the labor. 
and the dilatation of the os uteri may be etleetinl wiihoiu the h^ss ot' a 
drop of blood." Again, Simpson conclusively showed that when the 
'Sinolius, Arch. qcn. dc MaL, 18(U, vol. ii. 



412 LABOR. 

placenta was expelled before the birth of the child all hemorrhage 
ceased. 

Barnes' theory of placenta prsevia, which has been pretty generally 
adopted, explains satisfactorily both these classes of cases. He describes 
the uterine cavity as divisible into three zones or regions. When the 
placenta is situated in the upper or middle of these zones, no separa- 
tion or hemorrhage need occur during labor. When, however, it is 
situated partially or entirely in the lower or cervical zone, the expan- 
sion of the cervix during labor must produce more or less separation, 
and consequent loss of blood. As soon as the previous portion of the 
placenta is sufficiently separated, provided contraction of the uterine 
tissue be present to seal uj) the mouths of the vessels, hemorrhage no 
longer takes place. The placenta may not be entirely detached, but no 
further hemorrhage occurs, in consequence of the remaining portion 
being engrafted on the uterus beyond the region of unsafe attach- 
ment. 

In the former, then, of these classes of cases the absence of hemor- 
rhage is explained on this theory, by the pains being sufficiently rapid 
and strong to complete the separation of the placental attachment from 
the lower cervical zone before flooding had taken place ; in the latter 
it ceases, not necessarily because the entire placenta is expelled, but 
because of its detachment from the area of dangerous implantation. 

The amount of cervical expansion required for this purpose varies 
in different cases. Dr. Duncan^ estimates the limit of the spontaneous 
detaching area to be a circle of 4J inches diameter, and that after the 
cervix has expanded to that extent no fui'ther separation or hemorrhage 
takes place. To admit of the passage of a full-sized head, Barnes 
estimates that expansion to about a circle of 6 inches diameter is 
necessary ; on the other hand, he has sometimes observed " that the 
hemorrhage has completely stopped w^hen the os uteri opened to the 
size of the rim of a wine-glass or even less." 

It will be seen, then, that in this as in every other form of puerperal 
hemorrhage the tendency of uterine contraction is to check the hemor- 
rhage, and that, provided the pains are sufficiently energetic, Nature 
may be capable of stopping the flooding without artificial aid. It is 
but rarely, however, that she can be trusted for the purpose ; and we 
shall presently see that these theoretical views have an important prac- 
tical bearing on the subject of treatment. 

Prog-nosis. — The prognosis to both the mother and child is certainly 
grave in all cases of placenta prsevia. Read, in his treatise on placenta 
prsevia, estimates the maternal mortality, from the statistics of a large 
number of cases, as 1 in 4J cases, and Churchill as 1 in 3. This is 
unquestionably too high an estimate, and based on statistics the accuracy 
of which cannot be relied on. The mortality Avill, of course, greatly 
depend on the treatment adopted. Doubtless, if cases were left to 
nature the result would be quite as unfavorable as Read supposes. 
But if properly managed much more successful results may safely be 
anticipated. Out of 67 cases recorded by Barnes, the deaths were 6, 
or 1 in 8.5. Under any circumstances the risks to the mother are 

^ Obst. Trans., 1874, vol. xv. p. 189. 



HEMORRHAGE BEFORE DELIVERY. 413 

very great. Churchill estimates that more than half the children are 
lost. The reasons for the great danger to the child are very obvious, 
subjected as it is to the risk of asphyxia from the loss of the maternal 
blood, and from its respiration being carried on during labor by a i)la- 
centa which is only partially attached ; many children also perish from 
prematurity or from mal presentation. 

Treatment. — Whenever, in the latter months of pregnancy, a sudden 
hemorrhage occurs, the possibility of placenta prsevia will naturally 
suggest itself, and by a careful vaginal examination, which under such 
circumstances should always be insisted on, the existence of this com- 
plication will generally be readily ascertained. It is seldom that the 
OS is not sufficiently dilated to enable us to satisfy ourselves whether 
the placenta is presenting. 

The first question that will arise is, Are Ave justified in temporizing, 
using means to check the hemorrhage, and allowing the pregnancy to 
continue ? This is the course which has generally been recommended 
in works on midwifery. We are told to place the patient on a hard 
mattress, not to heat or overburden her with clothes, to keep her abso- 
lutely at rest, to have the room cool and well-aired, to apply cold cloths 
to the vulva and lower part of the abdomen, to administer cold and 
acidulated drinks in abundance, and to prescribe acetate of lead and 
opium or gallic acid on account of their supposed haemostatic effect. 
Of late years the judiciousness of these recommendations has been 
strongly contested. Not long ago an interesting discussion took place 
at the Obstetrical Society of London ^ on a paper in which Dr. Greeu- 
halgh advised the immediate induction of labor in all cases of placenta 
prsevia. No less than six metropolitan teachers of midwifery took part 
in it, and, although they differed in details, they all agreed as to the 
unadvisability of allowing pregnancy to progress when the existence 
of placenta prsevia had been distinctly ascertained. The reasons for 
this course are obvious and unanswerable. The labor, indeed, verv 
often comes on of its own accord, but should it not do so the patient's 
life must be considered to be always in jeopardy until the case is ter- 
minated, for no one can be sure that most dangerous, or even fatal, 
flooding may not at any moment come on ; and the nearer to term 
the patient is the greater the risk to Avhich she is subjected. Nor is 
the safety of the child likely to be increased by delay. Provided it 
has arrived at a viable age, the chances of its being born alive mav 
be said to be greater if pregnancy be terminated at once than if repeatixl 
floodings occur. I think, therefore, that it may be Siifely laid down as 
an axiom that no attempt should be made to prevent the termination of 
pregnancy, but that our treatment should rather contemplate its con- 
clusion as soon as possible. An exception may, however, be made to 
this rule when the hemorrhage occurs for the first time before the 
seventh month of utero-gestation. The chances of the child surviv- 
ing would then be very small, and if the henu>rrhage be not alarming, 
as at that early period is likely to be the ease, the measures indicattxl 
above may be employed in the hope of carrying on the ])rei:nanev until 
there is a prospect of the patient being delivered ot* a living child. 

^ Obskt. Trans., 1805, vol. vi. p. ISS. 



414 LABOB. 

But little benefit is likely to accrue from astriugent drugs. Perfect 
rest in bed is more likely to be beneficial than anything else; and 
astringent vaginal pessaries of matico or perch loride of iron might 
be used with advantage as local haemostatics. 

When the period of pregnancy or the urgency of the case determines 
us to forego any attempt at temporizing, there are various plans of treat- 
ment to be considered. These are, chiefly — 1. Puncture of the mem- 
branes ; 2. Plugging the vagina ; 3. Turning; 4. Partial or com- 
plete separation of the placenta. It will be well to consider in detail 
the relative advantages of, and indications for, each of these. It is 
seldom, however, that we can trust to any one pjer se; in most cases 
two or more are required to be used in combination. 

1. Puncture of the membranes is recommended by Barnes as the 
first measure to be adopted in all cases of placenta praevia sufficient to 
cause anxiety. "It is,'' he says, "the most generally efficacious remedy, 
and it can always be applied." The primary object gained is the in- 
crease of uterine contraction by the evacuation of the liquor amnii. 
Although the first effect of this may be to increase the flow of blood by 
further separation of the placenta, the flooding can generally be com- 
manded by plugging until the os is sufficiently dilated to permit the 
passage of the child. As a rule, there is no great difficulty in effecting 
the puncture, especially if the placental presentation be only partial. A 
quill or other suitable contrivance, guided by the examining finger, is 
passed through the cervix and pushed through the membranes. In 
complete placenta prsevia it may not be so easy to effect the evacua- 
tion of the liquor amnii, and although many authorities advise the 
penetration of the substance of the placenta itself, I am inclined to 
think that it would be better to abandon the attempt in such cases 
and trust to other methods of treatment. 

The objections which have been raised to puncture of the membranes 
are chiefly that it interferes with the gradual dilatation of the os and 
renders the operation of turning much more difficult. The os is not, 
however, so regularly dilated by the bag of membranes in cases of pla- 
centa praevia as it is in ordinary labors. Moreover, as the cervical 
tissues are generally relaxed by the hemorrhage, the dilatation is easily 
effected. Should we desire to dilate the os preparatory to turning, we 
can readily do so by means of Barnes' bags, which act at the same time 
as an efficient plug. The objections, therefore, are not so weighty as 
they might have been before these artificial dilators were used. I am 
inclined, for these reasons, to agree with the recommendation that 
puncture of the membranes should be resorted to in all cases of pla- 
centa prsevia. 

2. Plugging- of the vagina — or, still better, of the cavity of the 
cervix itself — is especially serviceable in cases in which the os is not 
sufficiently dilated to admit of turning or of separation of the placenta, 
and in which the hemorrhage still continues after the evacuation of the 
liquor amnii. By means of this contrivance the escape of blood is 
effectually controlled. 

The best way of plugging is to introduce a sponge tent of sufficient 
size into the cervical canal, and to keep it in situ by a vaginal plug ; the 



HEMORRHAGE BEFORE DELIVERY. 415 

best material for the latter, and the method of introduction, are described 
under the head of Abortion (p. 257). The sponge tent not only controls 
the hemorrhage more effectually than any other means, but is at the 
same time effecting dilatation of the cervix. It cannot be left in 
many hours, on account of the irritation produced and of the fetor 
from accumulating vaginal discharges, and the consequent risk of 
septic absorption. This is by no means slight, and it is now pretty 
generally recognized that the plug should not be used unless other 
means of treatment are inapplicable on account of the Avant of dila- 
tation of the OS. As long as it is in position we should carefully 
examine from time to time to see that no blood is oozing past it. 
If preferred, a Barnes bag may be used for the same purpose. 

While the plug is in situ other modes of exciting uterine action may 
be very advantageously employed, such as a firm abdominal bandage, 
occasional friction over the uterus, and repeated doses of ergot. The 
last is specially recommended by Dr. Greenhalgh, who used at the same 
time a plug formed of an oblong india-rubber ball inflated with air and 
covered with spongio-piline. 

On the removal of the plug we may find that considerable dilatation 
has taken place, perhaps to a sufficient extent to admit of labor being 
safely concluded by the natural efforts. In that case we shall find 
that, although the pains continue, no fresh hemorrhage occurs. Should 
it do so, it will be necessary to adopt further measures. 

3. Turning- has long been considered the remedy j9ar excellence in pla- 
centa prsevia, and it is of unquestionable value in suitable cases. Much 
harm, however, has been done when it has been practised before the os 
was sufficiently dilated to admit of the passage of the hand, or when 
the patient was so exhausted by previous hemorrhage as to be unable 
to bear the shock of the operation. The records of many fatal cases 
in the practice of those who taught, as did the large majority of the 
older writers, that turning at all risks was essential, conclusively 
prove this assertion. 

It is most likely to prove serviceable when, either at first or after 
the use of the tampon, the os is sufficiently dilated to admit the hand, 
and when the strength of the patient is not much enfeebled. If she 
have a small, feeble, and thready pulse it is certainly inapplicable, unless 
all other methods of arresting the hemorrhage have failed. And even 
then it would be well to attempt to rally the jxitient from her exhausteil 
state by stimulants, etc. before the operation is commenced. 

Provided the placental presentation be partial, the operation can be 
performed without difficulty in the usual way. In central implantation 
the passage of the hand may give rise to some difficulty. Dr. Rigbv 
reconnnends that it should be pushed through the substance of the 
])lacenta until it reaches the uterine cavity. It is hardlv possible to 
conceive how this could be done without completely detaching the pla- 
centa, and still less to understand how the fa^tus could be dragginl 
through the aperture thus made. It will be far better to pass the 
hand by the border of, the placenta, separating it as wi^ do >o: and 
if we can ascertain to which side of the cervix it is least attacluHl, that 
should be chosen lor the pur[)ose. In all cases iu which it is pivsible 



416 LABOR. 

turning by the bipolar method should be preferred. In cases of placenta 
prsevia especially it offers many advantages. The operation can be soou 
performed, complete dilatation of the os is not so necessary, and it in- 
volves less bruising of the cervix, which is likely to be specially 
dangerous. When once a lower extremity has been brought within 
the OS the delivery should not be hurried. The limb of the child forms 
a plug which effectually prevents all further loss ; and we may then wait 
until we can excite uterine contraction and terminate the labor a\ ith 
safety. The results of this method of treating placenta prsevia have 
been excellent. Hofmeier relates 37 cases managed in this Avay with 
only 1 death, and Behm 35 with none.^ [^] Fortunately, the relaxation 
of the uterus which is so often present facilitates this manner of per- 
forming version, and it can generally be successfully accomplished. 
Should the case be one which is otherwise suitable for turning, and 
the requisite amount of dilatation of the cervix not be present, the latter 
can generally be effected in the space of an hour or more (while at the 
same time a further loss of blood is effectually prevented) by the use of 
Barnes' bags. 

4. Entire separation of the placenta was originally recommended 
by Simpson in his well-known paper on the subject. The reasons which 
induced him to recommend it have already been stated. It is a mistake 
to suppose, however, as is so often done, that he intended to recommend 
it in all cases alike. This supposition he was always careful to deny. 
He advised it especially — 

(1) When the child is dead. 

(2) AYhen the child is not yet viable. 

(3) When the hemorrhage is great and the os uteri is not yet suffi- 
ciently dilated for safe turning. This was the state in 11 out of 39 
cases (Lee). 

(4) When the pelvic passages are too small for safe and easy 
turning. 

(5) When the mother is too exhausted to bear turning. 

(6) When the evacuation of the liquor amnii fails. 

(7) When the uterus is too firmly contracted for turning.^ 
These are very much the cases in which all modern accoucheurs 

would exclude the operation of turning; and it was especially Avhen 
that Avas unsuitable that Simpson advised extraction of the placenta. As 
his theory of the source of hemorrhage is now almost universally disbe- 
lieved, so has the practice based on it fallen into disuse, and it need not 
be discussed at length. It is very doubtful whether the complete sepa- 
ration and extraction of the placenta was a feasible operation ; unques- 
tionably, it can be by no means so easy as Simpson's writings would lead 
us to suppose. The introduction of the hand far enough to remove the 
placenta in an exhausted patient would probably cause as much shock as 
the operation of turning itself; and another very formidable objection 
to the procedure is the almost certain death of the child if any time 
elapse between the separation of the placenta and the completion of 

^Ztschr. f. Geburt unci Gyncik., 1882, Bd. viii. S. 89, and 1883, Bd. ix. 373: "Die 
combinirte Wendung bei Placenta Prgevia." 

['^ See full record at end of chapter.] ' Selected Obst. Works, p. 68. 



HEMORRHAGE BEFORE DELIVERY. 417 

delivery. The modification of this method so strongly advocated by 
Barnes is certainly much easier of application, and would appear to 
answer every purj)ose that Himpson's operation effected. It is impos- 
sible to describe it better than in Barnes' own words :^ 

" The operation is this : Pass one or two fingers as far as they will go 
through the os uteri, the hand being passed into the vagina if neces- 
sary; feeling the placenta, insinuate the finger between it and the ute- 
rine wall ; sweep the finger round in a circle so as to separate the pla- 
centa as far as the finger can reach ; if you feel the edge of the placenta 
where the membranes begin, tear open the membranes carefully, espe- 
cially if these have not been previously ruptured ; ascertain if you can 
what is the presentation of the child before withdrawing your hand. 
Commonly, some amount of retraction of the cervix takes place after 
the operation, and often the hemorrhage ceasesJ^ 

It will be seen from what has been said that no one rule of prac- 
tice can be definitely laid down for all cases of placenta prsevia. Our 
treatment in each individual case must be guided by the particular con- 
ditions that are present ; and if only we bear in mind the natural his- 
tory of the hemorrhage, we may confidently expect a favorable termi- 
nation. 

It may be useful, in conclusion, to recapitulate the rules which have 
been laid down for treatment in the form of a series of propositions : 

I. Before the child has reached a viable age temporize, provided the 
hemorrhage be not excessive, until pregnancy has advanced sufficiently 
to afford a reasonable hope of saving the child. For this purpose the 
chief indication is absolute rest in bed, to which other accessory means 
of preventing hemorrhage, such as cold, astringent pessaries, etc., mav 
be added. 

II. In hemorrhage occurring after the seventh month of utero-gesta- 
tion no attempt should be made to prolong the pregnancy. 

III. In all cases in which.it can be easily effected the membranes 
should be ruptured. By this means uterine contractions are favored 
and the bleeding vessels compressed. 

IV. If the hemorrhage be stopped the case may be left to nature. 
If flooding continue, and the os be not sufficiently dilated to admit of 
the labor being readily terminated by turning, the os and the vagina 
sh(3uld be carefully plugged, while uterine contractions are promoted bv 
abdominal bandages, uterine compression, and ergot. The plug must 
not be left in beyond a few hours, and careful antisepsis slunild be used. 

V. If on removal of the plug the os be sutHciently expanded and 
the general condition of the patient be good, the labor may be termi- 
nated by turning, the bipolar method being used if possible, and the 
lower extremity of the child will form a plug until delivery is com- 
pleted. If the OS be not open enough, it may be advantagvcnisl'.- 
dilated by a Barnes bag, which also acts as a ])lug. 

VJ. Instead of, or before resorting to, turning, the placenta mav Iv 
separated around the site of its attachment to the cervix. Iliis practiiv 
is specially to be preferre/:! when the patient is nuicli exliaustcnl and in 
a condition unfavorable for bearing the shock ot' turnino-. 

' Ob^i. Operations, LM od. p. tlT. 



418 LAB OB. 

[Dr. J. Braxton Hicks' biraanual method of turning-,^ as tested 
in Berlin by Drs. Hofmeier, Behm, and Lomer, promises much better 
results tlian any otlier method of treatment in cases of placenta pr?evia. 
According to Dr. Lomer's report in tlie Am. Journ. of Obstetrics for 
December^ 1884, Dr. Hofmeier operated upon 37 cases, and saved 36 
women and 14 children; Dr. Behm, upon 40 cases, all saved, but lost 
31 children ; and he himself, with eight other assistants, upon 101 cases, 
saving 94, with 50 children. This gives 8 deaths of women and 105 
of children in 178 cases, or a mortality of 4 J per cent, of the former 
and 60 per cent, of the latter. Dr. Lomer's directions are as follows : 
" Turn by the bimanual method as soon as possible ; pull down the leg, 
and tampon with it and with the breech of the child the ruptured vessels 
of the placenta. Bo not extract the child then: let it come by itself, or 
at least only assist its natural expulsion by gentle and rare tractions. Do 
away with the plug as much as possible ; it is a dangerous thing, for it 
favors infection and valuable time is lost with its application. Do not 
wait in order to perform turning until the cervix and the os are suffi- 
ciently dilated to allow the hand to pass. Turn as soon as you can pass 
one or two fingers through the cervix. It is unnecessary to force your 
finwrs through the cervix for this. Introduce the whole hand into the 
vagina, pass one or two fingers through the cervix, rupture the mem- 
branes, and turn by Braxton Hicks' bimanual method." . ..." If the 
placenta is in your way, try to rupture the membranes at its margin ; 
but if this is not feasible, do not lose time : perforate the placenta with 
your finger ; get hold of a leg as soon as possible, and bring it down.'^ 
—Ed.] 



CHAPTER XIY. 

HEMOREHAGE FEOM SEPAEATIOX OF A NOEMALLY-SITUATED 

PLACENTA. 

Definition. — This is the form of hemorrhage which is generally de- 
scribed in obstetric works as " accidental/^ in contradistinction to the 
^' unavoidable^^ hemorrhage of placenta prsevia. In discussing the lat- 
ter we have seen that the term " accidental '^ is one that is apt to mis- 
lead, and that the cause of the hemorrhage in placenta preevia is, in 
some cases at least, closely allied to that of the variety of hemorrhage we 
are now considering. 

When, from any cause, separation of a normally-situated placenta 

occurs before delivery, more or less blood is necessarily effused from the 

ruptured utero-placental vessels, and the subsequent course of the case 

may be twofold : 1. The blood, or at least some part of it, may find its 

\} Lancet, July, 1860 ; Obstetrical Transactions, vol. v. p. 222.] 



PLATE IV. 



Placenta] f^ite 



B]o(Hl-(:l(.t. 



Placental site j 



Placenta attached 
to wall producing 
its inversion 



Posterior wall of uterus 




Anterior wall 
of uterus 



Ketro-placental bloud-clot 




9 



Membranes 



Placenta 




^<t^;^" 



VERTICAL MKSIAL 8KCT10N OV I IKIUS WITH PLACKNTA PAUTIAI.I.Y A'nWCHED- 
froni a case of ubdoniiual section l\n- honiorrhago duviuy liax>r. Aflor BarUnir. 

{Tb jact poift no.) 



HEMORRHAGE BEFORE DELIVERY. 419 

way between the membranes and the decidua, and escape from the os 
uteri. This constitutes the typical ^^ accidental " hemorrhage of authors. 
2. The blood may fail to find a passage externally, and may collect in- 
ternally (see Plate IV.), giving rise to very serious symptoms, and even 
proving fatal, before the true nature of the case is recognized. Cases 
of this kind are by no means so rare as the small amount of attention 
paid to them by authors might lead us to suppose, and from the obscur- 
ity of the symptoms and difficulty of diagnosis they merit special study. 
Dr. GoodelP has collected together no less than 106 instances in which 
this complication occurred. 

Causes and Pathology. — The causes of placental separation may 
be very various. In a large number of cases it has followed an acci- 
dent or exertion (such as slipping down stairs, stretching, lifting heavy 
weights, and the like) which has probably had the effect of lacerating 
some of the placental attachments. At other times it has occurred with- 
out such appreciable cause, and then it has been referred to some change 
in the uterus, such as a more than usually strong contraction producing 
separation, or some accidental determination of blood causing a slight 
extravasation between the placenta and the uterine wall, the irritation 
of which leads to contraction and further detachment. Causes such as 
these, which are of frequent occurrence, will not produce detachment 
except in women otherwise predisposed to it. It generally is met with 
in women who have borne many children, more especially in those of 
weakly constitution and impaired health, and rarely in primipar?e. Cer- 
tain constitutional states probably predispose to it, such as albuminuria 
or exaggerated ansemia, and, still more so, degenerations and diseases of 
the placenta itself. 

This form of hemorrhage rarely occurs to an alarming extent until 
the latter months of pregnancy, often not until labor has commenced. 
The great size of the placental vessels in advanced pregnancy affords a 
reasonable explanation of this fact. 

Symptoms and Diagnosis. — If, after separation of a portion of the 
placenta, the blood finds its way between the membranes and the de- 
€idua, its escape ^3er vaglnam, even although in small amount, at once 
attracts attention and reveals the nature of the accident. It is other- 
wise when we have to do with a case of concealed liemorrhage, the 
diagnosis of which is often a matter of difficulty. Then the blood 
probably at first collects between the uterus and the placenta. Some- 
times marginal separation does not occur, and large blood-clots are 
formed in this situation and retained there, ^fore often the margin oi^ 
the placenta separates, and the blood collects between the membranes 
and the uterine wall, either toward the cervix, where the presentini:,- 
part of the child may prevent its escape, or near the I'undus. In the 
latter case especially the coagula are apt to cause very painful stretcliing 
and distension of the uterus. The blood may also find its wav into 
the amniotic cavity, but more frecpiently it does not do ^o, probal>ly. as 
(M)O(h^ll has ])ointed out, because, "shouhl the os uteri be closed, the 
membranes, liowever 'delicate, cannc^t, other things being equal, rupture 
any sooner from the uterine walls, for the sum ot' the resistance oi' the 

^ AuH'i: Jotini. of 01k^I<I., 18(>9-70, vol. ii. p. "JSl. 



420 LAB OB. 

enclosed liquor amnii, being equally distributed, exactly counterbalances 
the sum of the pressure exerted by the effusion/^ This point is of 
some practical importance, because after rupture of the membranes the 
liquor amnii is frequently found untinged with blood, and this might 
lead us to suppose ourselves mistaken in our diagnosis if this fact were 
not borne in mind. 

The most prominent symptoms in concealed internal hemorrhage are 
extreme collapse and exhaustion, for which no adequate cause can be 
assigned. These differ from those of ordinary syncope, with which they 
might be confounded, chiefly in their persistence and severity, and in 
the presence of the symptoms attending severe loss of blood, such as cold- 
ness and pallor of the surface, great restlessness and anxiety, rapid and 
sighing respiration, yawning, feeble, quick, and compressible pulse. 
AYhen there is severe internal with slight external hemorrhage we may 
be led to a proper diagnosis by observing that the constitutional symp- 
toms are much more severe than the amount of external hemorrhage 
would account for. Uterine pain is generally present of a tearing and 
stretching character, sometimes moderate in amount, more often severe, 
and occasionally amounting to intolerable anguish. It is often localized, 
and doubtless depends on the distension of the uterus by the retained 
coagula. If the distension be marked, there may be an irregularity in 
the form of the uterus at the site of sanguineous effusion ; but this Avill 
be difficult to make out, except in women with thin and unusually lax 
abdominal parietes. A rapid increase in the size of the uterus has been 
described as a sign by Cazeaux and others. It is not very likely that 
this will be appreciable toward the end of utero-gestation, as a very 
large amount of effusion would be necessary to produce it. At an 
earlier period of pregnancy, at or about the fifth month, I made it out 
very distinctly in a case in my own practice. It obviously must have 
occurred to an enormous extent in a case related by Chevalier, in which 
post-mortem Csesarean section was performed under the impression that 
the pregnancy had advanced to term, but only a three months' foetus 
was found imbedded in coagula which distended the uterus to the size 
of a nine months' gestation.^ Labor-pains may be entirely absent. If 
present they are generally feeble, irregular, and inefficient. 

Differential Diagnosis. — The only condition, besides ordinary syn- 
cope, likely to be confounded with this form of hemorrhage is rupture 
of the uterus, to which the intense pain and profound collapse induce 
considerable resemblance. The latter rarely occurs until after labor has 
been some time in progress and after the escape of the liquor amnii ; 
whereas hemorrhage usually occurs either before labor has commenced 
or at an early stage. The recession of the presentation and the escape 
of the foetus into the abdominal cavity in cases of rupture will further 
aid in establishing the diagnosis. 

Prognosis. — The prognosis Avhen blood escapes externally is, on the 
whole, not unfavorable. The nature of the case is apparent, and reme- 
dial measures are generally adopted sufficiently early to prevent serious 
mischief. It is diffi^rent with the concealed form, in which the mortal- 
ity is very great. Out of GoodelFs 106 cases no less than 54 mothers 

^ Journ. de Med. din. etpharm., vol. xxi. p. 363. 



HEMORRHAGE AFTER DELIVERY. 421 

died. This excessive death-rate is no doubt partly due to the fact that 
extreme prostration often occurs before the existence of hemorrhage is 
suspected, and partly to the accident generally happening in women of 
Aveakly and diseased constitutions. The prognosis to the child is still 
more grave. Out of 107 children, only 6 were born alive. The almost 
certain death of the child may be explained by the fact that w^hen blofxl 
collects between the uterus and the placenta the foetal portion of the lat- 
ter is probably lacerated, and the child then also dies from hemorrhage. 
Treatment. — In this as in all other forms of puerperal hemorrhage 
the great haemostatic is uterine contraction, and that we must try to 
encourage by all possible means. The first thing to be done, whether 
the hemorrhage be apparent or concealed, is to rupture the membranes. 
If the loss of blood be only slight, this may suffice to control it, and the 
case may then be left to nature. A firm abdominal binder should, how- 
ever, be applied to prevent any risk of blood collecting internally, as 
there is nothing to prevent its filling the uterine cavity after the mem- 
branes are ruptured. Contraction may be further advantageously solici- 
ted by uterine compression and by the administration of full doses of 
ergot. If hemorrhage continue, or if we have any reason to suspect 
concealed hemorrhage, the sooner the uterus is emptied the better. If 
the OS be sufficiently dilated, the best practice will be to turn without 
further delay, using the bipolar method if possible. If the os be not 
open enough, a Barnes bag should be introduced, while firm pressure is 
kept up to prevent uterine accumulation. Should the collapsed condition 
of the patient be very marked, the mere shock of the operation might 
turn the scale against her. Under such circumstances it may be better 
practice to delay further procedure until, by the administration of stim- 
ulants, warmth, etc., we have succeeded in producing some amount of 
reaction, keeping up, in the mean while, firm pressure on the uterus. 
Should the head be low down in the pelvis, it may be easier to complete 
labor by means of the forceps. 



CHAPTER XY. 

HEMORRHAGE AFTER DELIVERY. 

Its Importance. — Ilcmorrhage during or shortly after the third 
stage of labor is one of the most trying and dangerous accidents a^n- 
nected with parturition. Its sudden and unexpected occiu*renoo just 
after the labor a})})ear5 to be happily terminated, and its alarming etVect 
on the }>atient, who is often j)laced in the utmost danger in a few mo- 
ments, tax the presence of mintl and the resources o^ the practitioner 



422 LABOR. 

to the utmost, and render it an imperative duty on every one who 
practises midwifery to make himself thoroughly acquainted with its 
causes and preventive and curative treatment. There is no emergency 
in obstetrics which leaves less time for reflection and consultation, and 
the life of the patient will often depend on the prompt and immediate 
action of the medical attendant. 

Frequency of Post-partum Hemorrhage. — Post-partum hemor- 
rhage is one of the most frequent complications of delivery. I do not 
know of any statistics which enable us to judge with accuracy of its fre- 
quency, but I believe it to be an imquestionable fact that, especially in 
the upper ranks of society, it is very common indeed. This is probably 
due to the eifects of civilization and to the mode of life of patients of 
that class, whose whole surroundings tend to produce a lax habit of 
body which favors uterine inertia, the principal cause of post-partum 
hemorrhage. In the report of the Registrar-General for the five yeai^s 
from 1872 to 1876, 3524 deaths are attributed to flooding. The 
majority of these must have been caused by post-partum hemorrhage, 
although some may have been from other forms. 

Fortunately, it is, to a great extent, a preventable accident. I 
believe this fact cannot be too strongly impressed on the practitioner. 
If the third stage of labor be properly conducted, if eveiy case be 
treated, as every case ought to be, as if hemorrhage were impending, 
it would be much more infrequent than it is. It is a curious fact that 
post-partum hemorrhage is mtich more common in the practice of some 
medical men than in that of others, the reason being that those who 
meet with it often are careless in the management of their patients 
immediately after the birth of the child. That is just the time when 
the assistance of a properly cpialified practitioner is of value, much more 
so than before the second stage of labor is concluded ; hence when I hear 
that a medical man is constantly meeting with severe post-partum hem- 
orrhage I hold myself justified, ijjso facto, in inferring that he does not 
know or does not practise the proper mode of managing the third stage 
of labor. 

Causes. — The placenta, as we have seen, is separated by the last 
pains, and the blood, which in greater or less qtiantity accompanies the 
fcetus, probably comes from the utero-placental vessels which are then 
lacerated. Almost immediately afterward the uterus contracts firmly, 
and in a tyj^ical labor assumes the hard cricket-ball form which is so 
comforting to the accoucheur to feel. (See Plate V.) The result is the 
compression of all the vascular trunks which ramify in its walls, both 
arteries and veins, and thus the flow of l)lood through them is pre- 
vented. By referring to what has been said as to the anatomy of the 
mtLscular fibres of the gravid uterus, especially at the placental site 
(p. 62), it will be seen how admirably they are adapted for this pur- 
pose. The arrangement of the vessels themselves favors the haemo- 
static action of uterine contraction. The large venous sinuses are placed 
in layers one above the other in the thickness of the titerine walls, and 
they anastomose freely. AVhen the superimposed layers communicate 
with those immediately below them, the junction is by a falciform or 
semilunar opening in the floor of the vessel nearest the external surface 



HEMORRHAGE AFTER DELIVERY. 423 

of the uterus. Within the margins of this aperture there are muscular 
fibres, the contraction of which probably tends to prevent retrogression 
of blood from one layer of vessels into the other. The venous sinuses 
themselves are of a flattened form, and they are intimately attached to 
the muscular tissues. It is obvious, then, that these anatomical arrange- 
ments are eminently adapted to facilitate the closure of the vessels. 
They are, however, large, and are destitute of valves ; and if contrac- 
tion be absent or if it be partial and irregular, it is equally easy to 
understand why blood should pour forth in the appalling amount 
which is sometimes observed. 

If uterine action be firm, regular, and continuous, the vessels must 
be sealed up and hemorrhage effectually prevented. This fact has 
been doubted by many authorities. Gooch was the first to describe 
what he called ^^ a peculiar form of hemorrhage '^ accompanying a 
contracted womb. Similar observations have been made by other 
writers, such as Yelpeau, Rigby, and Gendrin. Simpson says on this 
point that strong uterine contractions "are not probably so essential 
a part in the mechanism of the prevention of hemorrhage from the 
open orifices of the uterine veins as we might a priori suppose." ^ With 
regard to Gooch's cases, it has been pointed out that his own descrip- 
tion proves that, however firmly the uterus may have contracted imme- 
diately after the expulsion of the child, it must have subsequently 
relaxed, for he passed his hand into it to remove retained clots — a 
manoeuvre which he could not have practised had tonic contraction 
been present. In some of these cases the hemorrhage has been found 
to come from a laceration of the cervix. Of course blood may readily 
escape from mechanical injury of this kind, although the uterus itself 
be in a satisfactory state of contraction ; and the possibility of this 
occurrence should always be borne in mind. Instances of the success- 
ful treatment of this variety of post-partum hemorrhage by sutures 
applied to the lacerated cervix have been related by Fallen and 
others. 

Although, then, we may admit that post-partum hemorrhage is 
incompatible with persistent contraction of the uterus, it by no means 
follows that the converse is true. On the contrary, it is not uncommon 
to meet with cases in which iha uterus is large, and ap}>arently quite 
flaccid, and in which there is no loss of blood. Alternate relaxation 
and contraction of the uterus after delivery are also of constant occur- 
rence, and yet hemorrhage during the relaxation does wox take place. 
The explanation no doubt is that immediately after the birth of the 
child there was sufficient contraction to prevent hemorrhage, and tha: 
during its continuance coagula formed in the mouths of the uterine 
sinuses by which they were suiliciently occluded to prevent any los6 
when subsequent relaxation occnrrcHl. 

In all probability, both uterine contraction and thrombosis are in 
operation in ordinary cases; and we shall presently soe that all the 
means enq)loyed in the treatment of post-partinu henionhngo act by 
})rodiicing one or oth'er of them. 

Uterine inertia after labor, then, may be regarded as the one groat 

1 Sdci'tcd OhMct. ]\'orks, p. 234. 



424 LAB OB. 

primary cause of post-partum hemorrhage; but there are various 
secondary causes which tend to produce it, one of the most frequent 
of which is exhaustion following a protracted labor. The uterus gets 
worn out by its efforts, and when the foetus is expelled it remains in a 
relaxed state and hemorrhage results. Over-distension of the uterus 
acts in the same way. Hence hemorrhage is very frequently met with 
when there has been an excessive amount of liquor amnii or in multi- 
ple pregnancies. One of the worst cases I ever met with was after the 
birth of triplets, the uterus having been of an enormous size. Rapid 
emptying of the uterus, during which there has not been sufficient time 
for complete separation of the placenta, often tends to the same result. 
This is the reason why hemorrhage so frequently follows forceps delivery, 
especially if the operation have been unduly hurried ; and it is one of 
the chief dangers in what are termed " precipitate labors.'^ The gen- 
eral condition of the patient may also strongly predispose to it. Thus, 
it is more often met with in women who have borne families, especially 
if they be weakly in constitution, comparatively seldom in primiparse, 
and for the same reason that after-pains are most common in the former 
— namely, that the uterus, weakened by frequent childbearing, contracts 
inefficiently. The experience of practitioners in the tropics shows that 
European women, debilitated by the relaxing effects of warm climates, 
are peculiarly prone to it, and it forms one of the chief dangers of child- 
birth amongst the English ladies in India. 

Another important cause of post-partum hemorrhage is partial and 
irregular contraction of the uterus. Part of the muscular tissue is 
firmly contracted, while another part is relaxed, and the latter very 
often the placental site. This has been especially dwelt on by Simp- 
son. He says : '^ The morbid condition which is most frequently and 
earliest seen in connection with post-partum hemorrhage is a state of 
irregularity, and want of equability in the contractile action of differ- 
ent parts of the uterus — and, it may be, in different planes of the mus- 
cular fibres — as marked by one or more points in the organ feeling hard 
and contracted at the same time that other portions of the parietes are 
soft and relaxed.^' 

One peculiar variety, which has been much dwelt on by writers, and 
is a prominent bugbear to obstetricians, is the so-called ^'hour-glass eon- 
traction.''^ This, in reality, seems to depend on spasmodic contraction 
of the internal os uteri, by means of which the placenta becomes 
encysted in the upper portion of the uterus, which is relaxed. On 
introducing the hand it first passes through the lax cervical canal, until 
it comes to the closed internal os, with the umbilical cord passing through 
it, w^hich has generally been supposed to be a circular contraction of a 
portion of the body of the uterus. 

Encystment of the placenta, however, although more rarely, unques- 
tionably takes place in a portion only of the body of the uterus (Fig. 
149). Then, apparently, the placental site remains more or less para- 
lyzed, with the placenta still attached, while the remainder of the body 
of the uterus contracts firmly, and thus encystment is produced. 

These irregular contractions of the uterus are by no means so common 
as our older authors supposed. When they do occur, I believe them 



HEMORRHAGE AFTER DELIVERY. 



425 



almost invariably to depend on defective management of the third 
stage of labor. "The most frequent cause/^ says Rigby/ "is from 
over-anxiety to remove the placenta ; the cord is frequently pulled at, 
and at length the os uteri is excited to contract.'^ While this is being 
done no attempts are probably being made to excite the fundus to 



Fig. 149. 





Regular Contraction of the Uterus, with Encystment of the Placenta. 



proper action, and therefore the hour-glass contraction is established. 
Johnstone^ has pointed out that in a large proportion of cases ergot 
has been given before the expulsion of the placenta. Duncan says of 
this condition : " Hour-glass contraction cannot exist unless the parts 
above the contraction are in a state of inertia ; were the higher parts 
of the uterus even in moderate action, the hour-glass contraction would 
soon be overcome.^' ^ If placental expression were always em})loyed, 
if it were the rule to effect the expulsion of the placenta by a vis Cl 
tergo instead of extracting by a vis a fronte, I feel confident that these 
irregular and spasmodic contractions — of the influence of which in pro- 
ducing hemorrhage there can be no question — would rarely if ever be 
met with. It is to be observed that even in these cases it is not because 
the uterus is in a state of partial contraction, but because it is in a state 
of partial relaxation, that hemorrhage ensues. 

Placental Adhesions. — Adhesions of the placenta to the uterine 
parietes may cause hemorrhage, especially if they be partial and the 
remainder of the placenta be detached. The frequency of these has 
been over-estimated. Many cases believed to be examples of adherent 
phu^entiie are, in reality, only cases of placenta^ retained from uterine 
inertia. The experience of all who see nuieh midwitery will probably 
corroborate the observation of Braun, that " abnormal adhesions and hour- 
glass contraction are more frequently encountered in the experience of 
the young practitioner, and they diminish in tVe(|uent>y in direct ratio to 
increasing years." '^ The cause oi' adhesions is oiten obsciuv, but it most 
probably results from *a morbid state of the decidiia, which is produc«.\l 

XXV ii. p. ISS. 



1 Rigby's Midwlfcni, p. 2'2n. 
^ RescairhcK in Obf<(c(rics, p. oS9. 



■^ GlasgoH' 3[ed. Jouru., ISS7. vol. 
* Rrauu's Lectnir^, ISOO. 



426 LABOR. 

bv antecedent disease of the uterine mucous membrane; then the 
adhesion is apt to recur in subsequent pregnancies. The decidua is 
altered and thickened, and patches of calcareous and fibrous degenera- 
tion may be often found on the attached surface of the placenta. Most 
frequently the placenta is only partially adherent, patches of it remain 
firmly attached to the uterlis, while the rest is separated; hence the 
uterine walls remain relaxed and hemorrhage frequently follows. The 
diagnosis and management of these very troublesome cases will be &und 
described under tlie head of treatment (p. 42 9 j. 

Finally, I think it must be admitted that there are some women who 
really merit the appellation of "flooders" which has been applied to 
them, and who, do what we may, have the most extraordinary tendency 
to hemorrhage after delivery. I do not think that these cases, however, 
ai'e by any means so common as some have supposed. I have attended 
several patients who have nearly lost their lives from post-partum hem- 
orrhage in former labors, some who have suffered from it in every pre- 
ceding confinement, and I have only met with two cases in which the 
assiduous use of preventive treatment failed to avert it. In these (one 
of which I have elsewhere published in detaiP), in spite of all my 
efforts, I could not succeed in keeping up uterine contraction, and the 
patients Avould certainly have lost their lives were it not for the means 
which modern improvements have fortunately placed at our disposal 
for producing thrombosis in the mouths of the bleeding vessels. The 
nature of these rare cases requires further investigation : possibly they 
may, to some extent, be the subjects of the so-called hemorrhagic 
diathesis. 

The loss of blood may commence immediately after the birth of 
the child before the expulsion of the placenta, or not until some time 
afterward, when the contracted uterus has again relaxed. It may com- 
mence gradually or suddenly : in the latter case it may begin with a 
gush, and in t]ie worst form the bedclothes, the bed, and even the floor, 
are deluged with the blood which, it is no exaggeration to say, is pour- 
ing from the patient. If now the hand be placed on the abdomen, we 
shall miss the hard round ball of the contracted uterus, which will be 
found soft and flabby, or we may even be unable to make out its contour 
at all. If the hemorrhage be slight or if we succeed in controlling it at 
once, no serious consequences follow ; but if it be excessive or if we fail 
to check it, the gravest results ensue. 

There are few sights more appalling to witness than one of the worst 
cases of post-partum hemorrhage. The pulse becomes rapidly affected, 
and may be reduced to a mere thread or it may become entirely imper- 
ceptible. Syncope often comes on — not in itself always an unfavorable 
occurrence, as it tends to promote thrombosis in the venous sinuses; or, 
short of actual syncope, there may be a feeling of intense debility and 
faintness. Extreme restlessness soon supervenes, the j^atient throws her- 
self about the bed, tossing her arms wildly above her head; respiration 
becomes gasping and sighing, the "besoin de respirer" is acutely felt, 
and the patient cries out for more air; the skin becomes deadly cold and 
covered with profuse perspiration : if the hemorrhage continue unchecked, 

^ Obst. Journ., 1873-74, vol. i. p. 89. 



HEMORRHAGE AFTER DELIVERY. 427 

we next may have complete loss of vision, jactitation, convulsions, aud 
death. 

Formidable as such symptoms are, it is satisfactory to know that 
recovery often takes place, even when the powers of life seem reduced 
to the lowest ebb. If we can check the hemorrhage while there is still 
some power of reaction left, however slight, we may not unreasonably 
hope for eventual recovery. The constitution, however, may have 
received a severe shock, and it may be months, or even years, before 
the patient recovers from the eifects of only a few minutes' hemor- 
rhage. A death-like pallor frequently follows these excessive losses, 
and the patient often remains blanched and exsanguine for a long time. 

Treatment. — The preventive treatment of post-partum hemor- 
rhage should be carefully practised in every case of labor, however 
normal. If the practitioner make a habit of never removing his hand 
from the uterus after the birth of the child until the placenta is expelled, 
and of keeping up continuous uterine contraction for at least half an 
hour after delivery is completed, not necessarily by friction on the 
fundus, but by simply grasping the contracted womb with the palm of 
the hand and preventing its undue relaxation, cases of post-partum 
flooding will seldom be met with. As a rule, Ave should, I think, not 
apply the binder until at least that time has elapsed. The binder is an 
effective means of keeping up, but not of producing, contraction, and it 
should never be trusted to for the latter purpose. If it be put on too 
soon, the uterus may relax under it, and become filled with clots with- 
out the practitioner knowing anything about it ; whereas this cannot 
possibly take place as long as the uterine globe is held in the hollow of 
the hand. I have seen more than one serious case of concealed hemor- 
rhage result from the too common habit of putting on the binder imme- 
diately after the removal of the placenta. I believe also, as I have 
formerly said, that it is thoroughly good practice to administer a full 
dose of the liquid extract of ergot in all cases after the placenta has been 
expelled, to ensure persistent contraction and to lessen the chance of 
blood-clots being retained in utcro. 

These are the precautions which should be used in all cases alike ; 
but when we have reason to fear the occurrence of hemorrhage from 
the history of previous labors or other cause, special care should be 
taken. The ergot should be given, and i)referably in the form of the 
subcutaneous injection of ergotine, before the birth of the child, when 
the presentation is so far advanced that we estimate that labor will be 
concluded in from ten to twenty minutes, as we can hardly expect the 
drug to produce any effect in less time. I*articular attention, moreover, 
should then be paid to i\\Q state of the uterus. Every means should be 
taken to ensure regular and strong contraction, and it is advisable to 
rupture the membranes early, as soon as the os is dilated or dilata- 
ble, to ensure stronger uterine action. Jf any tendiMuy to relaxation 
occur after delivery, a piece of ice should be passed into the vagina 
or into the uterus. Shonhl eoagula collect in the ntertis. thev mav be 
readily expelled by lirili pressiu'c on the fundus, and the tinger sln>iild 
be passed occasionally u[) to the cervix, and any which are tell there 
should be gently picked away. 



428 LABOR. 

AVe slionld be specially on our guard in all cases in which the pulse 
does not fall after delivery. If it beat at 100 or more some ten minutes 
or a quarter of an hour after the birth of the child, hemorrhage not un- 
frequently follows; and hence it is a good practical rule, which may save 
much trouble, that a patient should never be left unless the pulse has 
fallen to its natural standard. 

As there are only two means which nature adopts in the prevention 
of post-partum hemorrhage, so the remedial measures also may be 
divided into two classes: 1. Those which act by the production of 
uterine contraction; 2. Those which act by producing thrombosis in 
the vessels. Of these the first are the most commonly used ; and it is 
only in the worst cases, in which they have been assiduously tried 
and have failed, that we resort to those coming under the second 
heading. 

The patient should be placed on her back, in which position we can 
more readily command the uterus as well as attend to her general state. 
If the uterus be found relaxed and full of clots, by firmly grasping it 
in the hand contraction may be evoked, its contents expelled, and fur- 
ther hemorrhage at once arrested. Should this fortunately be the case, 
we must keep up contraction by gently kneading the uterus until we 
are satisfied that undue relaxation will not recur. 

The powerful influence of friction in promoting contraction cannot 
be doubted, and nothing will replace it; no doubt it is fatiguing, but as 
long as it is effectual it must be kept up. Xo roughness should be used, 
as we might produce subsequent injury, but it is quite possible to use 
considerable pressure without any violence. 

Another method of applying uterine pressure has been strongly advo- 
cated by Dr. Hamilton of Falkirk, and it may be serviceable where 
there is a constant draining from the uterus and a capacious pelvis. It 
consists in passing the fingers of the right hand high up into the pos- 
terior cul-de-sac of the vagina, so as to reach the posterior surface of 
the uterus, while counter-pressure is exercised by the left hand through 
the abdomen. The anterior and posterior walls of the uterus are thus 
closely pressed together. 

During the time that pressure is being applied attention can be paid 
to general treatment ; and in giving his directions to the bystanders the 
practitioner should be calm and collected, avoiding all hurry and 
excitement. A full dose of ergot should be administered, and if one 
have already been given, it should be repeated. We cannot, however, 
look upon ergot as anything but a useful accessory, and it is one which 
requires considerable time to operate. The hypodermic use of ergotine 
offers the double advantage, in severe cases, of acting with greater 
power and much more rapidly than the usual method of administra- 
tion. It should, therefore, always be used in preference. An aqueous 
solution of ergotinine, ^^ of a grain in 10 minims, has been highly 
recommended by Chahbazain of Paris as acting more energetically, and, 
it lias seemed to me,^ has had a good effect. 

The sudden flow will probably have produced exhaustion and a tend- 
ency to syncope, and the administration of stimulants will be necessaiy. 

^ Obst. Trans, for 1882, vol. xxiv. p. 286. 



HEMORRHAGE AFTER DELIVERY. ' 429 

The amount must be regulated by the state of the pulse and the degree 
of exhaustion. There is no more absurd mistake, however, than im- 
plicitly relying on the brandy-bottle to check post-partum hemorrhage. 
In the worst cases absorption is in abeyance, and brandy may be poured 
down in abundance, the j^ractitioner believing that he is rousing his 
patient, while he is, in fact, only filling the stomach with a quantity of 
fluid which is eventually thrown up unaltered. I have more than once 
seen symptoms produced by the over-free use of brandy in slight flood- 
ings which were certainly not those of hemorrhage. I remember on 
one occasion being summoned by a practitioner, with a view to transfu- 
sion, to a patient who was said to be insensible and collapsed from hem- 
orrhage. I found her, indeed, unconscious, but with a flushed face, a 
bounding pulse, a firmly contracted uterus, and deep stertorous breath- 
ing. On inquiry I ascertained that she had taken an enormous quan- 
tity of brandy, which had brought on the coma of profound intoxica- 
tion, while the hemorrhage had obviously never been excessive. 

The hypodermic injection of sulphuric ether is a remedy of great 
value as a powerful stimulant in cases in which exhaustion is very 
great. It has the advantage of acting rapidly, and of being capable of 
administration when the patient is unable to swallow. A fluiddrachm 
may be injected into the nates or thigh, and the injection may be re- 
peated as the state of the patient may require. 

The window should be thrown widely open to allow a current of 
fresh cold air to circulate freely through the room. The pillows should 
be removed, the head kept low, and the patient should be assiduously 
fanned. 

If bleeding continue or if it commence before the placenta is 
expelled, the hand should be carefully and gently passed into the uterus 
and its cavity cleared of its contents. The mere presence of the hand 
within the uterus is a powerful inciter of uterine action. AVhen the 
placenta is retained it is the more essential, as the hemorrhage cannot 
possibly be checked as long as the uterus is distended by it. During 
the operation the uterus should be supported by the left hand exter- 
nally, and by using the. two hands in concert the chances of injuring 
the textures are greatly lessened. 

Treatment of Hour-glass Contraction. — If the so-called '' Ikhu- 
glass contraction " be present or if the placenta be morbidly adherent, 
the operation will be more difficult and Avill require nuich judgment 
and care. The spasmodic contraction of the inner os in the former 
case may generally be overcome by gentle and continuous pressure o^ 
the fingers passed within the contraction, while the uterus is supported 
from without. By this means, too, further hemorrhage can in most 
cases be controlled until the spasm is sutficiently relaxed to atlniit oi^ 
the passage of the hand. 

Signs of Adherent Placenta. — There are no very reliable signs to 
indicate morbid adhesion of the placenta previous to the introduction 
of the hand. The following are the symptoms as laid down bv Barnes, 
any of which might, h'owever, accompany non-detachniont o\' the }>la- 
centa unaccompanied by adhesion : '' You may suspect morbid adhesion 
if there have been unusual ditViculty in ivmoving the placenta in pre- 



430 LABOE. 

\^ous la1x)rs ; if during the third stage the uterus coutracts at intervals 
firmlvj each contraction being accompanied bv blood, and yet on follow- 
ing up the cord you feel the placenta in ufero; if on pulling on the 
cord, two fingers being pressed into the placenta at the root, vou feel 
the plac-euta and uterus descend in one mass, a sense of dragging pain 
being elicired : if during a pain the uterine tumor does not present a 
globular form, V)ut be more prominent than usual at the place of pla- 
cental anachment." ' 

Treatment of Adherent Placent-a. — The artificial removal of an 
adherent placenta is always a delicate and anxious operation, which, 
however carefully |3erformed. must of necessity expose the patient to 
the risk of iujiuy to the uterine structures, and of leaving behind por- 
tions of placental tissue which may give rise to secondarv hemorrhage 
or septicaemia. The cord will guide the hand to the site of attachment, 
and the fingers must l>e very gently insinuated l>etween the lower edge 
of the placenta and the uterine wall ; or if a portion be alreadv de- 
tached we may commence to peel off the remainder at that spot. Sup- 
porting the uterus externally, we carefully pick off as much as possible, 
proceeding with the greatest caution, as it is by no means easy to dis- 
tinguish l>etween the placenta and the uterus. At the best, it is far 
from easy to remove all, and it is wiser to separate only wliat we read- 
ily can than to make too protracted efforts at complete detachment, 
^len it is found to be impossible to detach and remove the whole or a 
great part of the placenta, we cannot but look u}X)n the further prog- 
ress of the case with considerable anxiety. The retained portions may 
be ere long spontaneously detached and expelled, or they may decom- 
pose and give rise to fetid discharge and septic infection. Such cases 
must ^ye treated by antiseptic intra-uterine injections, so as to lessen the 
risk of absorption as much as possible : but until the retained masses 
have been expelled and the discharge has ceased the patient must l>e 
regaixled as in considerable danger. In a few rare c-ases there is reason 
to believe that masses of retained placental tissue have been entirely- 
absorbed. It is difficult to understand so strange a phenomenon, but 
several well-authenticated cases are recorded in which there seems no 
reason to doubt that the retained placenta was removed in this way.- 

Various means are used for exciting uterine conti*action by refiex 
stimulation. Amongst the most important of these is cold. In patients 
who are not too exhausted to respond to the stimulus applied, it is of 
extreme value. But to be of use it should l>e used intermittently and 
not continuously. Pom'ing a stream of cold water from a height on 
the alxlomen is a not uncommon, but bad practice, as it deluges the pa- 
tient and the bedding in water, which may afterward act injuriously. 
Flapping the lower part of the alxlomen with a wet towel is less objec- 
tionable. Ice can generally be obtained, and a piece should l>e intro- 
duced into the uterns. This is a ver^* jx)werful haemostatic, and often 
excites strong action when other means fail. I constantly employ it, 
and have never seen any bad results follow. A large piece of ice may 

^ Obstetric Optrofion.?. p. 440. 

' See an interesting paper bv Dr. Thrush on " Eetention of the Placenta in Labor at 
Term." Amer. Journ. of Ohstet.. 1S77. vol. x. pp. 389, 506. 



HEMORRHAGE AFTER DELIVERY. 431 

also be held over the fundus, and removed and reapplied from time to 
time. Iced water may be injected into the rectum. A veiy powerful 
remedy is washing out the uterine cavity with a stream of cold water 
by means of the vaginal pipe of a Higginson's syringe carried up to 
the fundus. Another means of applying cold, said to be very effectual, 
is the application of the ether spray, such as is used for producing local 
anaesthesia, over the lower part of the abdomen.^ All these remedies, 
however, depend for their good results on the fact of the patient being 
in a condition to respond to stimulus, and their prolonged use, if they 
foil to excite contraction rapidly, will certainly prove injurious. Ivigby 
used to look upon the application of the child to the breast as one of 
the most certain inciters of uterine action. It may be of service after 
the hemorrhage has been checked in keeping up tonic contraction, and 
should therefore not be omitted ; but Ave certainly cannot waste time in 
inducing the child to suck in the face of the actual emergency. 

Of late, intra-uterine injections of hot water at a temperature of 
from 100° to 120° have been highly recommended as a powerful means 
of arresting post-partum hemorrhage, often proving effectual when all 
other treatment has failed. The number of published cases in which it 
has proved of great value is now considerable. The present master of 
the Rotunda, Dr. Lombe Atthill, has recorded 16 cases ^ in which it 
checked hemorrhage at once, in many of which ergot, ice, and other 
means had failed. He speaks of it as especially useful in those trouble- 
some cases in which the uterus alternately relaxes and hardens, and 
resists all our efforts to produce permanent contraction. Its superiority 
to cold water has been well shown by Milne Murray ^ by means of 
experiments on pregnant and non-pregnant rabbits, which proved that 
while cold applications produce a temporary contraction, when applied 
for any length of time they rapidly exhaust the excitability of the ute- 
rine muscle, while the reverse effect is produced when hot water is used. 
My own experience of this treatment is very flivorable. I liave now 
used it in several cases, in some of which the tendency to hemorrhage 
was very great, and in every instance it has at once pi-oduced strong 
uterine action and instantly checked the flow. It is, moreover, much 
more agreeable to the patient than cold application?. I think it cannot 
be doubted that we have in these warm irrigations a valuable addition 
to our methods of treating uterine hemorrhage. [Hot-water injections, 
to be effective, should have a temperature of about 1 1 5^. Water simplv 
'warm — that is, only a little above blood-heat — favors the hemorrhagic 
loss. — Ed.] 

The late Dr. Earle pointed out^ that a distended bladder often pre- 
vents contraction, and to avoid the possibility of this the catheter 
should be passed. 

Plugging of the vagina has often been used. It is only neivssarv to 
mention it for the purpose of insisting on its absolute inapplicability in 
all cases of post-partum hemorrhage; the only etfect it could have 
would be to prevent the esca})e of blood externally, which niioht then 
collect to any extent* in the cavity of the uterus. 

^Grifliths, Rmditioner, 1877, vol. xviii. p. I7l>. ' Lnncd, Fobrnary i), I 

^ Edin. Med. Jonni., 1 880-87, pp. lol. 'Jlo. * Kurlo's Floodino after DdivtTi/, 



after Delivi^ru, p. IGo. 



432 LABOR. 

Compression of the abdominal aorta is highly thonght of by many 
continental authorities, but it is little known or practised in England. 
It has been objected to by some on the theoretical ground that the hem- 
orrhage is chiefly yenous, and not arterial , and that it would only fay or 
tlie reflux of yenous blood into the yena caya. Cazeaux points out that 
on account of the close anatomical relations between the aorta and the 
vena cava it is hardly possible to compress one yessel without the other. 
The backward flow of blood, therefore, through the vena cava may also 
be thus arrested. There is strong evidence in favor of the occasional 
utility of compression. Its chief recommendation is that it can be prac- 
tised immediately, and by an assistant who can be shown how to apply 
the pressure. It is most likely to prove useful in sudden and severe 
hemorrhage, and if it only control the loss for a few moments it gives 
us time to apply other methods of treatment. As a temporary expedi- 
ent, therefore, it should be borne in mind and adopted when necessary. 
It has the great advantage of supplementing, without superseding, other 
and more radical plans of treatment. The pressure is very easily 
applied, on account of the lax state of the abdominal walls. The artery 
can readily be felt pulsating above the fundus uteri, and can be com- 
pressed against the vertebrae by three or four fingers applied lengthways. 
Baudelocque, who was a strong advocate of this procedure, stated that 
he had on several occasions controlled an otherwise intractable hemor- 
rhage in this way, and that he on one occasion kept up compression for 
four consecutive hours. Cazeaux believes that compression of the aorta 
may have a further advantageous efifect in retaining the mass of the 
blood in the upper part of the body, and thus lessening the tendency to 
syncope and collapse. If an aortic tourniquet, such as is used for com- 
pressing the vessel in cases of aneurism, could be obtained, it might be 
used with advantage in such cases. 

If a battery is at hand the faradic current may be used, and is, it is 
said, a very powerful agent in inducing uterine contraction, one pole 
being introduced into the uterus, the other applied over it through the 
abdominal parietes. 

AVhen the hemorrhage has been excessive and there is profound 
exhaustion, firm bandaging of the extremities, by preference with 
Esraarch\s elastic bandages if they can be obtained, may be advanta- 
geously adopted, with the view of retaining the blood as much as pos- 
sible in the trunk, and thus lessening the tendency to syncope. As a 
temporary expedient in the worst class of cases it may occasionally prove 
of service. 

[Lives of patients in extremis' hay e been saved by the expedient of 
raising the body of the woman and lowering her head, so as to turn the 
current of blood toward the brain. This may have to be repeated sev- 
eral times in the treatment of a case where attacks of syncope indicate 
it. A bladder containing ice may be held under the hand of the ope- 
rator over the abdomen and above the fundus uteri, and compression 
made upon the uterus and aorta at the same time. In one case I was 
forced, by the long-continued inertia of the uterus and the tendency to 
a return of hemorrhage, to keep up this form of compression for six and 
a half hours. The hand of the operator should be protected by a com- 



HEMORRHAGE AFTER DELIVERY. 43'j 

press of flannel^ or he may have an attack of local neuralgia, or possibly 
rheumatism, in his arm. — Ed.] 

Supposing these means fail, and the uterus obstinately refuses to con- 
tract in spite of all our efforts — and, do what we may, cases of this kind 
will occur — the only other agent at our command is the application of 
a powerful styptic to the bleeding surface to produce thrombosis in the 
vessels. ^' The latter,^' says Dr. Ferguson,^ alluding to this means of 
arresting hemorrhage, ^' appears to be the sole means of safety in those 
cases of intense flooding in which the uterus flaps about the hand like 
a wet towel. Incapable of contraction for hours, yet ceasing to ooze out 
a drop of blood, there is nothing apparently between life and death but 
a few soft coagula plugging up the sinuses.'^ These form but a frail 
barrier indeed, but the experience of all who have used the injection of 
perch loride of iron in such cases proves that they are thoroughly effec- 
tual, and their introduction into practice is one of the greatest improve- 
ments in modern midwifery. Although this method of treating these 
obstinate cases is not new, since it was practised long ago in Germany, 
its adoption in England is unquestionably due to the energetic recom- 
mendation of Dr. Barnes. Although the dangers of the practice have 
been strongly insisted on, and with a degree of acrimony that is to be 
regretted, I know of only one published case in which its use has been 
followed by any evil effects. Its extraordinary power, however, of 
instantly checking the most formidable hemorrhage has been demon- 
strated by the unanimous testimony of all who have tried it. As it is 
not proposed by any one that this means of treatment should be employed 
until all ordinary methods of evoking contraction have failed, and as in 
cases of this kind the lives of the patients are of necessity imperilled, 
we should be fully justified in adopting it, even if its possibly injurious 
effects had been much more certainly proved. It is surely at anv time 
justifiable to avoid a great and pressing peril by running a possible 
chance of a less one. Whenever, therefore, we have tried the plans 
above indicated in vain, no time should be lost in resorting to this expe- 
dient. No practitioner should attend a case of midwifery without hav- 
ing the necessary styptic with him. The best and most easily obtain- 
able form of using the remedy is the ^^ liquor ferri perchloridi fortior " 
of the London Pharmacopoeia, which should be diluted for use with six 
times its bulk of water. This is certainly better than a weaker solution. 
The vaginal pipe of a Higginson's syringe, through which the solution 
has once or twice been pumped to exclude the air, is guided by the hand 
to the fundus uteri and the fluid injected gently over the uterine surface. 
The loose and flabby mucous membrane is instantaneouslv felt to pucker 
up, all i\\(i blood with which the fluid comes in contact is coagulated, 
and ihci hemorrhage is immediately arrested. I think it is of import- 
ance to make sure that the uterus and vagina are empticxl of clots before 
injection. In the only cases in which I have seen any bad symptoms 
follow this precaution had been neglected. The iron hardeniHl all the 
coagula, which had remaincnl hi iifcro, and septicaemia supervomnl ; 
which, however, disa[)peared after the clots had been broken u[> and 
washed away by intra-uterine antiseptic injections. After we have 

' Preface to Gooch On J)iW(it<i\^ of Women, p. xlii.. Now v^vdonh:uu JSooioiv. lS-39. 

28 



434 LABOR. 

resorted to this treatment all further pressure on the uterus should be 
stopped. \Ye must remember that Ave have now abandoned contraction 
as a hsemostatic, and are trusting to thrombosis, and that pressure might 
detach and loosen the coagula which are preventing the escape of 
blood. 

Other local astringents may be eventually found to be of use. Tinc- 
ture of matico possibly might be serviceable, although I am not aware 
that it has been tried. Dupierris has advocated tincture of iodine, 
and. has recorded 24 cases in which he employed it, in all without acci- 
dent and with a successful issue. Penrose strongly recommends com- 
mon vinegar, which has the advantage of being always readily obtain- 
able. [^] But nothing seems likely to act so immediately or so effectu- 
ally as the perchloride of iron. 

Hemorrhag-e from Laceration of Maternal Structures. — A word 
may here be said as to the occasional dependence of hemorrhage after 
delivery on laceration of the cervix or other injury to the maternal soft 
parts. Duncan has narrated a case in which the bleeding came from a 
ruptured perineum. If hemorrhage continue after the uterus is per- 
manently contracted, a careful examination should be made to ascertain 
if any such injury exist. Most generally the source of bleeding is the 
cervix, and the flow can be readily arrested by swabbing the injured 
textures with a sponge saturated in a solution of the perchloride. 

The secondary treatment of post-part um hemorrhage is of import- 
ance. When reaction commences a train of distressing symptoms often 
show themselves, such as intense and throbbing headache, great intoler- 
ance of light and sound, and general nervous prostration ; and when 
these have passed away Ave have to deal Avith the more chronic effects 
of profuse loss of blood. Nothing is so valuable in relie\^ing these 
symptoms as opium. It is the best restorative that can be employed, 
but it must be administered in larger doses than usual. Thirty to 
forty drops of Battley's solution should be given by the mouth or in 
an enema. At the same time the patient should be kept perfectly still 
and quiet in a darkened room, and the visits of anxious friends strictly 
forbidden. Strong beef-essence or gravy soup, milk, or eggs beaten up 
Avith milk, and similar easily absorbed articles of diet, should be giA^en 
frequently and in small quantities at a time. Stimulants Avill be required 
according to the state of the patient, such as warm brandy-and-water, 
port Avine, etc. Rest in bed should be insisted on, and continued much 
beyond the usual time. Eventually, the remedies Avhich act by promot- 
ing the formation of blood, such as the A'arious preparations of iron, 
Avill be found useful, and may be required for a length of time. 

Under the head of Transfusion I have separately treated the applica- 
tion of that last resource in those desperate cases in Avhich the loss of 
blood has been so excessive as to leaA^e no other hope. 

Secondary Post-partum Hemorrhag-e. — In the majority of cases, 
if a fcAV hours haA^e elapsed after delivery Avithout hemorrhage we may 
consider the patient safe from the accident. It is by no means A^ery 

[^This remedy was used as a uterine injection with signal effect in a case of violent 
post-partum hemorrhasce by a French surgeon in country practice in the days of Astruc, 
who wrote of it in 1765 {Maladies des Femmes, vol. iv. p. 227). — Ed.] 



HEMORRHAGE AFTER DELIVERY. 435 

rare, however, to meet with even profuse losses of blood coming on in 
the course of convalescence at a time varying from a few hours or days 
up to several weeks after delivery. These cases are described as exam- 
ples of '^ secondary hcmorrhage,^^ and they have not received at all an 
adequate amount of attention from obstetric writers, inasmuch as they 
often give rise to very serious, and even fatal, results, and are always 
somewhat obscure in their etiology and difficult to treat. We owe 
almost all our knowledge of this condition to an excellent paper by Dr. 
McClintock of Dublin, who has collected characteristic examples from 
the writings of various authors, and accurately described the causes 
which are most apt to produce it. 

We must, in the first place, distinguish between true secondary hemor- 
rhage and profuse lochial discharge continued for a longer time than 
usual. The latter is not a very uncommon occurrence, and is generally 
met with in cases in which involution of the uterus has been checked, 
as by too early exertion, general debility, and the like. The amount 
of the lochial discharge varies in different women. In some patients 
it habitually continues during the whole puerperal month, and even 
longer, but not to an extent which justifies us in including it under 
the head of hemorrhage. In such cases prolonged rest, avoidance of 
the erect posture, occasional small doses of ergot, and, it may be, after 
the lapse of some weeks astringent injections of oak-bark or alum, will 
be all that is necessary in the way of treatment. 

True secondary hemorrhage is often sudden in its appearance and 
serious in its effects. McClintock mentions 6 fatal cases, and Mr. 
Bassett of Birmingham^ has recorded 13 examples which came under 
his own observation, 2 of which ended fatally. 

The causes may be either constitutional or some local condition of 
the uterus itself. 

Constitutional Causes. — Among the former are such as produce a 
disturbance of the vascular system of the body generally or of the 
uterine vessels in particular. The state of the uterine sinuses, and 
the slight barrier which the thrombi formed in them offer to the 
escape of blood, readily explain the fact of any sudden vascular con- 
gestion producing hemorrhage. Thus, mental emotions, the sudden 
assumption of the erect posture, any undue exertion, the incautious 
use of stimulants, a loaded condition of the bowels, or sexual inter- 
course shortly after delivery, may act in this way. McClintock records 
the case of a lady in whom very profuse hemorrhage occurred on the 
twelfth day aftcu* labor, when sitting up for the first time. Feeling 
faint after suckling, the nurse gave her st)me brandy, whereupon a gush 
of blood ensued, " deluging all the bed-clothes and penetrating through 
the mattress so as to form a pool on the floor." Here the ercvt position, 
the exquisite pain caused by nursing, and the stinuilating drink, all 
concurred to excite the hemorrhage. Tn another instance the flooding 
was traced to excitement produced by the sudden return o( an old lover 
i)n the eighth day after labor. Morcau especially dwells on the influ- 
ence of local congestion produced by a loadcnl condition ot' the rectum. 
■Constitutional affections, [)roducing gem^ral di^Hlity ;uul an impover- 

' Bri(. Med. Jouru., IST'J. vol. ii. pp. '2\i.\ tOl. 



436 LABOR. 

ished state of the blood, probably also may have the same effect. Blot 
specially mentions albuminuria as one of these, and Saboia states that 
in Brazil secondary hemorrhage is a common symptom of miasmatic 
poisoning, and can only be cured by change of air and the free use of 
quinine.^ 

Local Causes. — Local conditions seem, however, to be the more fre- 
quent factors in the j^roduction of secondary hemorrhage. These may 
be generally classed under the following heads : 

1. Irregular and inefBcient contraction of the uterus. 

2. Clots in the uterine cavity. 

3. Portions of retained placenta or membranes. 

4. Ketrollexion of the uterus. 

5. Laceration or inflammatory state of the cervix. 

6. Thrombosis or hsematocele of the cervix or vulva. 

7. Inversion of the uterus. 

8. Fibroid tumors or polypus of the uterus. 

The first four of these need only now be considered, the others being- 
described elsewhere. 

Relaxation of the uterus and distension of its cavity by coagula may 
give rise to hemorrhage, although not so readily as immediately after 
delivery, for coagula of considerable size are often retained in utero for 
mauv davs after labor. The uterus will be found laro;er than it ouo^ht 

» » (Do 

to be, and tender on pressure. Usually the coagula are expelled with 
severe after-pains ; but this may not take place, and hemorrhage may 
ensue several days after delivery. Or there may be only a relaxed state 
of the uterus without retained coagula. Bassett relates 4 cases traced 
to these causes, and several illustrations will be found in McClintock's 
paper. Portions of retained placenta or membranes are more frequent 
causes. The retention may be due to carelessness on the part of the 
practitioner, especially if he have removed tlie placenta by traction and 
failed to satisfy himself of its integrity. It may, however, often be 
due to circumstances entirely beyond his control, such as adherent pla- 
centa, which it is impossible to re.move without leaving portions in utero, 
or more rarely placenta succenturia. In the latter case there is a small 
supplementary portion of placental tissue developed entirely separate 
from the general mass, and it may remain in utero without the prac- 
titioner having the least suspicion of its existence. Portions of the 
membranes are very apt to be left in utero. It is to prevent this that 
they should be twisted into a rope and extracted very gently after 
expression of the ])lacenta. Hemorrhage from these causes generally 
does not occur until at least a week after delivery, and it may not do 
so until a much longer time has elapsed. In 4 cases recorded by Mr. 
Bassett it commenced on the tenth, twelfth, fourteenth, and thirty-second 
day. It may come on suddenly, and continue, or it may stop, and recur 
frequently at short intervals. In my experience retention of portions 
of the placenta is very common after abortion, when adhesions are more 
generally met with tlian at term. In addition to the hemorrhage there 
is often a fetid discharge, due to decomposition of the retained portion, 
and possibly more or less marked septicsemic symptoms, which may aid 
^ Saboia, Traite des Accouchements, p. 819. 



HEMORRHAGE AFTER DELIVERY. 437 

in the diagnosis. The placenta or membranes may simgly be lying 
loose as foreign bodies in the uterine cavity, or they may be organi- 
cally attached to the uterine walls, when their removal will not be so 
easily effected. 

Barnes has especially pointed out the influence of retroflexion of the 
uterus in producing secondary hemorrhage,^ which seems to act by im- 
peding the circulation at the point of flexion and thus arresting the pro- 
cess of involution. 

Treatment. — In every case in which secondary hemorrhage occurs to 
any extent, careful investigation into the possible causes of the attack and 
an accurate vaginal examination are imperatively required. If it be due 
to general and constitutional causes only, we must insist on the most 
absolute rest on a hard bed in a cool room, and on the absence of 
all causes of excitement. The liquid extract of ergot will be very gen- 
erally useful in sj doses repeated every six liours. McClintock strongly 
recommends the tincture of Indian hemp, which may be advantageously 
combined with the ergot in doses of 10 or 15 minims, suspended in 
mucilage. Astringent vaginal pessaries of matico or perchloride of iron 
may be used. Special attention should be paid to the state of the 
bowels, and if the rectum be loaded it should be emptied by ene- 
mata. In more chronic cases a mixture of ergot, sulphate of iron, 
and small doses of sulphate of magnesia will prove very serviceable. 
This is more likely to be effectual when the bleeding is of an atonic 
and passive character. McClintock speaks strongly in favor of the 
application of a blister over the sacrum. When the hemorrhage is ex- 
cessive more effectual local treatment will be required. Cazeaux advises 
plugging of the vagina. Although this cannot be considered so 
dangerous as immediately after delivery, inasmuch as the uterus is 
not so likely to dilate above the plug, still it is certainly not entirely 
without risk of favorino; concealed internal hemorrhaw. If it be used 
at all, a firm abdominal pad should be applied, so as to compress 
the uterus, and the abdomen should be examined from time to time 
to ensure against the possibility of uterine dilatation. With these pre- 
cautions the plug may prove of real value. In any case of really 
alarming hemorrhage I should be disposed rather to trust to the ap- 
plication of styptics to the uterine cavity. The injection of fluid iu 
bulk, as after delivery, could not be safely practised, on account of the 
closure of the os and the contraction of the uterus. But there can be 
no objection to swabbing out the uterine cavity with a small ])iece of 
sponge attached to a handle and saturated in a solution of the ]Hnvhlo- 
ride of iron. Tliere are few cases which will resist this treatment. 

If we have reason to suspect retained placenta or membranes, or if the 
hemorrhage continue or recur after treatment, a careful exploration ot' 
the interior of the Avomb will be essential. On vaginal exaniinntion we 
may possibly feel a portion of tlu^ placenta pi-otnuling through the os, 
which can then be removed without difliculty. It' the os bo closinl, it 
must be dilated with sponge or laminaria tents or by a small-siztHl 
Barnes bag, and the uterus can then be thoroughlv exj^lorinl. This 
ought to be (lone under chlorotbnn, as it cannot be etVeetually aeeoni- 

^ Obstdric Opiradonti, p. 49*J. 



438 LABOR. 

plished without introcluciEg the whole hand into the vagina, which 
necessarily causes much paiu. If the placenta or membranes be loose 
in the uterine cavity, they may be removed at once, or if they be organ- 
ically attached, they may be carefully picked off. The uterus should at 
the same time, as long as the os remains patulous, be thoroughly 
washed out with Condy's fluid and water to diminish the risk of 
septicaemia. 

Retroflexion can readily be detected by vaginal examination, and the 
treatment consists in careful reposition with the hand and the application 
of a large-sized Hodge's pessary. 



CHAPTER Xyi. 
EUPTURE OF THE UTEEUS, ETC. 

Rupture of the uterus is one of the most dangerous accidents of 
labor, and until of late years it has been considered almost necessarily 
fatal and beyond the reach of treatment. Fortunately, it is not of very 
frequent occurrence, although the published statistics vary so much that 
it is by no means easy to arrive at any conclusion on this point. The 
explanation is, no doubt, that many of the tables confound partial and 
comparatively unimportant lacerations of the cervix and vagina with 
rupture of the body and fundus. It is only in large lying-in institu- 
tions, where the results of cases are accurately recorded, that anything 
like reliable statistics can be gathered, for in private practice the occur- 
rence of so lamentable an accident is likely to remain unpublished. To 
show the difference between the figures given by authorities, it may be 
stated that, while Burns calculates the proportion to be 1 in 940 labors, 
lugleby fixes it as 1 in 1300 or 1400, Churchill as 1 in 1331, and Leh- 
maun as 1 in 2433. Dr. Jolly of Paris has published an excellent 
thesis containing much valuable information.^ He finds that out of 
782,741 labors, 230 ruptures, excluding those of the vagina or cervix, 
occurred — that is, 1 in 3403. 

Lacerations may occur in any part of the uterus — the fundus, the 
body, or the cervix. Those of the cervix are comparatively of small 
consequence, and occur, to a slight extent, in almost all first labors. 
Only those which involve the supravaginal portion are of really serious 
import. Ruptures of the upper part of the uterus are much less frequent 
than of the portion near the cervix ; partly, no doubt, because the fundus 
is beyond the reach of the mechanical causes to which the accident can, 
not unfrequently, be traced, and partly because the lower third of the 
organ is apt to be compressed between the presenting part and the bony 
pelvis. The site of placental insertion is said by Madame La Chapelle 

^ Rupture uterine pendant le Travail, Paris, 1873. 



RUPTURE OF THE UTERUS, ETC. 439 

to be rarely involved in the rupture, })ut it does not always escape, jis 
numerous recorded cases prove. The most frequent seat of rupture is 
near the junction of the body and neck, either anteriorly or posteriorly, 
opposite the sacrum, or behind the symphysis pubis, but it may occur at 
the sides of the lower segment of the uterus. In some cases the entire 
cervix has been torn away, and separated in the form of a ring. 

The laceration may be partial or complete, the latter being the more 
common. The muscular tissue alone may be torn, the peritoneal coat 
remaining intact ; or the converse may occur, and then the peritoneum 
is often fissured in various directions, the muscular coat being un impli- 
cated. The extent of the injury is very variable, in some cases being 
only a slight tear, in others forming a large aperture, sufficiently exten- 
sive to allow the foetus to pass into the abdominal cavity. The direction 
of the laceration is as variable as the size, but it is more frequently ver- 
tical than transverse or oblique. The edges of the tear are irregular and 
jagged; probably on account of the contraction of the muscular fibres, 
which are frequently softened, infiltrated with blood, and even gangren- 
ous. Large quantities of extravasated blood will be found in the perito- 
neal cavity; such hemorrhage, indeed, being one of the most important 
sources of danger. 

The causes are divided into predisposing and exciting ; and the prog- 
ress of modern research tends more and more to the conclusion that the 
cause which leads to the laceration could only have operated because tlie 
tissue of the uterus was in a state predisposed to rupture, and that it 
would have had no such effect on a perfectly healthy organ. AVhat 
these predisposing changes are, and how they operate, is yet far from 
being known, and the subject offers a fruitful field for pathological 
investigation. 

It is generally believed that lacerations are more common in mul- 
tiparse than in primiparte. Tyler Smith contended that ruptures are 
relatively as common in first as in subsequent labors, while Baudl ^ found 
that only 64 cases out of 546 ruptures were in primiparse. Statistics 
are not sufficiently accurate or extensive to justify a ])ositive conclusion, 
but it is reasonable to sup})ose that the pathological changes presently to 
be mentioned as predisposing to laceration are more likely to be met with 
in women whose uteri have frequently undergone the alteration attend- 
ant on repeated pregnancies. Age seems to have considerable infiuence, 
as a large proportion of cases have occurred in women between thirty and 
forty yeai's of age. 

Alterations in the tissues of the uterus are probably ot' very great 
importance in predisposing to the accident, ahhough our information on 
this ])oint is far from accurate. Among these are morbid states of the 
nniscular fibres, the result of blows and contusions during pregnancy : 
premature fatty degeneration of the nuiseidar tissues, an anticipation, as 
it were, of the normal involution after delivery; fibi'oiil tumors t>r malig- 
nant infiltration of the uterine walls, which either ])roduce a morbid state 
of tlu^ tissues or act as an impediment to the expulsion k^^ the fanns. 
Tlu» importance of such changi^s has been specially dwelt on by Mur- 
})liy in this country and by Lehniann in (icrniany. and it is impossible 

^ Ucbcr Riiptur dtr Gthiinnuttcr, Wioii, ISlo. 



440 LABOR. 

not to concede their probable influence in favoring laceration. How- 
ever, as yet these views are founded more on reasonable hypothesis than 
on accurately observed pathological facts. 

Another and very important class of predisposing causes are those 
which lead to a want of proper proportion between the pelvis and the 
fcetus. 

Deforniity of the pelvis has been very frequently met with in cases 
in which the uterus has ruptured. Thus, out of 19 cases carefully 
recorded by Radford,^ the pelvis was contracted in 11, or more than one- 
half. Eadford makes the curious observation that ruptures seem more 
likely to occur when the deformity is only slight, and he explains this 
by supposing that in slight deformities the lower segment of the uterus 
engages in the brim, and is therefore much subjected to compression, 
while in extreme deformity the os and cervix uteri remain above the 
brim, the body and fundus of the uterus hanging down between the 
thighs of the mother. This explanation is reasonable, btit the rarity with 
which ruptured uterus is associated with extreme pelvic deformity may 
rather depend on the infrequency of advanced degrees of contraction. 

Bandl, who has made the most important of modern contributions to 
our knowledge of the subject, points out that rupture nearly always 
begins in the lower segment of the uterus, which becomes abnormally 
stretched and distended when from any cause the expulsion of the 
fcetus is delayed. The upper portion of the uterus becomes at the 
same time retracted and much thickened. (See Fig. 150.) As the pains 
continue, the stretching of the lower segment, called by Spiegelberg 
the " obstetrical cervix," becomes more and more marked imtil at last 
its fibres separate and a laceration is established. The Hue of demar- 
cation between the thickened body and the distended lower segment, 
known as the ring of Bandl, can in such cases be occasionally made out 
by palpation above the pubes. 

Amongst causes of disproportion depending on the fcetus are either 
malpresentation, in which the pains cannot effect expulsion, or undue 
size of the presenting part. In the latter way may be explained the 
observation that rupture is more frecpiently met with in the delivery of 
male than of female children, on account, no doubt, of the larger size 
of the head in the former. The influence of intra-uterine hydrocej^h- 
alus was first prominently pointed out by Sir James Simpson,- who states 
that out of 74 cases of intra-uterine hydrocephalus the uterus ruptured 
in 16. In all such cases of disproportion, whether referable to the pel- 
vis or fcetus, rupture is j^roduced in a twofold manner — either by the 
excessive and fruitless uterine contractions which are induced by the 
efforts of the org^an to overcome the obstacle, or by the compression of 
the uterine tissue between the presenting part and the bony pelvis, lead- 
ing to inflammation, softening, and even gangrene. 

The proximate cause of rupture may be classed under two heads — 
mechanical injury and excessive uterine contraction. Under the 
former are placed those imcommon cases in which the uterus lace- 
rates as the result of some injury in the latter months of pregnancy, 
such as blows, falls, and the like. Xot so rare, unfortunately, are lace- 

' Obst. Trans., 1S67, vol. viii. p. 150. -Selected Obstetric Works, p. 3S5. 



RUPTURE OF THE UTERUS, ETC. 441 

rations produced by unskilled attempts at delivery on the part of the 
medical attendant, such as by the hand during turning or by the blades 
of the forceps. Many such cases are on record in which the accoucheur 
has used force and violence, rather than skill, in his attempts to over- 
come an obstacle. That such unhappy results of ignorance are not so 
uncommon as they ought to be is proved by the figures of Jolly, who 

Fig. 150. 




Illustrating the Dangerous Thinning of the Lower Segment of Uterus, owing to uon-descent of 
head in a case of intra-uterine hydrocephalus. (After Bandl.) 

has collected 148 cases of rupture of the uterus ; of which 71 occurred 
during version by the feet; 37 under the use of the forceps ; 10 under 
that of the cephalotribe, and 30 during other operations, the precise 
nature of which is not stated.^ The modus operandi of protractai 
and ineffectual uterine contractions as a proximate cause of rup- 
ture is sufficiently evident, and need not be dwelt on. It is neces- 
sary to allude, however, to the effect of ergot, incautiously adminis- 
tered, as a producing cause. There is abundant evidence that the 
injudicious exhibition of this drug has often been followed by lace- 
ration of the unduly stimulated uterine fibres. Thus, Trask, talking ,>f 
the subject, says that INIeigs had seen 3 cases, anil Bedford 4, distinctly 
traceable to this cause. Jolly found that ef-got had been administeri\l 
largely in 33 cases in^ which rupture occurred. 

Premonitory Symptoms. — 8ome have believed that the impending 
occurrence of rupture could frequently be aseenained by peculiar pix^ 

^ Op. cit. 



442 LABOR. 

monitory symptoms, such as excessive and acute crampy pains about the 
lower part of the abdomen, due to the compression of part of the uterine 
walls. These are far too indefinite to be relied on, and it is certain that 
the rupture generally takes place without any symptoms that would have 
afforded reasonable grounds for suspicion. 

The g-eneral symptoms are often so distinct and alarming as to leave 
no doubt as to the nature of the case. Not infrequently, however, especi- 
ally if the laceration be partial, they are by no means so well marked, 
and the practitioner may be uncertain as to what has taken place. In the 
former class of cases a sudden excruciating pain is experienced in the 
abdomen, generally during the uterine contractions, accompanied by a 
feeling on the part of the patient of something having given way. 
In some cases this has been accompanied by an audible sound Avhich 
has been noticed by the bystanders. At the same time, there is gener- 
ally a considerable escape of blood from the vagina, and a prominent 
symptom is the sudden cessation of the previously strong pains. 
Alarming general symptoms soon develop, partly due to shock,, 
partly to loss of blood, both external and internal. The face ex- 
hibits the greatest suffering, the skin becomes deadly cold and covered 
with a clammy sweat, and fainting, collapse, rapid feeble pulse, hurried 
breathing, vomiting, and all the usual signs of extreme exhaustion 
quickly follow. 

Abdominal palpation and vaginal examination both afford character- 
istic indications in well-marked cases. If the child, as often happens, 
has escaped entirely or in great part into the abdominal cavity, it may 
be readily felt through the abdominal walls; while in the former case 
the partially-contracted uterus may be found separate from it in the 
form of a globular tumor resembling the uterus after delivery. Per 
vaginam, it can generally be ascertained that the presenting part has sud- 
denly receded and is no longer to be made out, or some other part of the 
foetus is found in its place. If the rupture be extensive, it may be 
appreciable on vaginal examination, and sometimes a loop of intestine 
will be found protruding through the tear. Other occasional signs have 
been recorded, such as an emphysematous state of the lower part of the 
abdomen, resulting from the entrance of air into the cellular tissue or the 
formation of a sanguineous tumor in the hypogastrium or vagina. These 
are too uncommon and too vague to be of much diagnostic value. 

Unfortunately, the symptoms are by no means always so distinct, and 
cases occur in which most of the reliable indications, such as the sudden 
cessation of the pains, the external hemorrhage, and the retrocession of 
the presenting part, may be absent. In some cases, indeed, the symp- 
toms have been so obscure that the real nature of the case has only 
been detected after death. It is rarely, however, that the occurrence 
of shock and prostration is not sufficiently distinct to arouse suspicion, 
even in the absence of the usual marked signs. In not a few cases dis- 
tinct and regular contractions have gone on after laceration, and the 
child has even been born in the usual Avay. Of course in such a case 
mistake is very possible. So curious a circumstance is difficult of expla- 
nation. The most probable way of accounting for it is, that the lacera- 
tion has not implicated the fundus of the uterus, which contracted suf- 



RUPTURE OF THE UTERUS, ETC. 443 

ficiently energetically to expel the ffctus. Hence it will be seen that 
the symptoms are occasionally obscure, and the practitioner must be 
careful not to overlook the occurrence of so serious an accident because 
of the absence of the usual and characteristic symptoms. 

The prognosis is necessarily of the gravest possible character, but 
modern views as to treatment perhaps justify us in saying that it is not 
so absolutely hopeless as has been generally taught in our ol)stetric 
works. When we reflect on what has occurred — the profound nervous 
shock ; the profuse hemorrhage, both external, and, especially, into the 
peritoneal cavity, where the blood coagulates and forms a foreign body; 
the passage of the uterine contents into the abdomen, with the inevita- 
ble result of inflammation and its consequences if the patient survive 
the primary shock, — the enormous fatality need cause no surprise. Jolly 
has found that out of 580 cases 100 recovered ; that is, in the propor- 
tion of 1 out of 6. This is a far more favorable result than we are 
generally led to anticipate ; and as many of the recoveries happened in 
apparently the most desperate and unfavorable cases, Ave should learn 
the lesson that we need not abandon all hope, and should at least 
endeavor to rescue the patient from the terrible dangers to which she 
is exposed. 

As regards the child, the prognosis is almost necessarily fatal ; and, 
indeed, the cessation of the foetal heart-sounds has been pointed out by 
McClintock as a sign of rupture in doubtful cases. The shock, the 
profuse hemorrhage, and the time that must necessarily elapse before 
the delivery of the child are of themselves quite sufficient to explain 
the fact that the foetus is almost always dead. 

Treatment. — From what has been said of the impossibility of fore- 
telling the occurrence of rupture, it must follow that no reliable pro- 
phylactic treatment can be adopted beyond that which is a matter of 
general obstetric principle — viz. timely interference when the uterine 
contractions seem incapable of overcoming an obstacle to delivery, 
either on the part of the pelvis or foetus. 

After rupture the main indications are to eff'eet the removal of the 
child and tlie placenta, to rally the patient from the effects of the siiock, 
and, if she survives so long, to combat the subsequent inflammation and 
its consequences. By far the most im})ortant point to decide is the best 
means to be adopted for the removal of the child, for it is admitted by 
all that the hopeless expectancy that was recommended by the older 
accoucheurs — or, in other words, allowing the patient to die without 
making any effort to save her — is quite inadmissible. If the fcvtus bo 
entirely within the uterine cavity, no doubt the i)roper course to ]nn-sue 
is to deliver at once per rias })afur(rlcs, either by turning, by force})s, or 
by cephalotri})sy. If any part other tluin the head present, turning 
will be best, great care being taken to avoid further increase ot' thi^ lace- 
ration. If the head be in the cavity or at the brim of the pelvis :nul 
within easy reach of the forceps, it may be cautiously ai>plied, tlie child 
being steadied by abdominal [>ressure so as to facilitate its application. 
If there be, as is often the case, some slight amount of pelvic contrac- 
tion, it may be preferable to perforate and a]>plv the cephalotrihc, so 
as to avoid any forcible attempts at extraction which might unduly 



444 LABOR. 

exhaust the already prostrate patient and turn the scale against her. 
This will be the more allowable since the child is^ as we have seen, 
almost always dead, and we might readily ascertain if it be so by 
auscultation. 

After delivery extreme care must be taken in removing the placenta, 
and for this it will be necessary to introduce the hand. The placerita 
will generally be in the uterus, for if the rent be not large enough for 
the child to pass through, it may be inferred that the placenta will not 
have done so either. If it has escaped from the uterus, very gentle 
traction on the cord may bring it within reach of the hand, and so 
the passage of the hand through the tear to search for it will be 
avoided. 

There can be but little doubt that in the cases indicated such is the 
proper treatment and that which affords the mother the best chance. 
Unfortunately, the cases in which the child remains entirely in utero 
are comparatively uncommon, and generally it will have escaped into 
the abdomen, along with much extravasated blood. The usual plan of 
treatment recommended under such circumstances is to pass the hand 
through the fissure (some have even recommended that it should be 
enlarged by incision if necessary), to seize the feet of the foetus, to drag 
it back through the torn uterus, and then to reintroduce the hand to 
search for and remove the placenta. Imagine what occurs during the 
process. The hand groj^es blindly among the abdominal viscera, the 
forcible dragging back of the foetus necessarily tears the uterus more 
and more, and, above all, the extravasated blood remains as a foreign 
body in the peritoneal cavity, and necessarily gives rise to the most 
serious consequences. It is surely hardly a matter of surprise that 
there is scarcely a single case on record of recovery after this pro- 
cedure. 

Of late years a strong feeling has existed that whenever the child 
has entirely or in great part escaped into the abdominal cavity the ope- 
ration of gastrotomy affords the mother a far better chance of recovery ; 
and it has now been performed in many cases with the most encourag- 
ing results. It is easy to see why the prospects of success are greater. 
The uterus being already torn and the peritoneum opened, the only 
additional danger is the incision of the abdominal parietes, which gives 
us the opportunity of sponging out the peritoneal cavity as in ovariot- 
omy, and of removing all the extravasated blood, the retention of which 
so seriously adds to the dangers of the case. Another advantage is 
that if the patient be excessively prostrate the oj^eration may be delayed 
until she has somewhat rallied from the effects of the shock, whereas 
delivery by the feet is generally resorted to as soon as the rupture is 
recognized, and when the patient is in tlie worst possible condition for 
interference of any kind. 

Jolly has carefully tabulated the results of the various methods of 
treatment, and, making every allowance for the unavoidable errors of 
statistics, it seems beyond all question that the results of gastrotomy are 
so greatly superior to those of other plans that I think its adoption may 
fairly be laid down as a rule whenever the foetus is no longer within the 
uterine cavity : 



RUPTURE OF THE UTERUS, ETC. 



44; 



Comparative Results of Various Methods of Treatment after 
Rupture of Uterus. 



Treatment. 



Expectation 

Extraction per vias nature 
Gastrotomy ...... 



No, of 
Cases. 



144 

382 
38 



Deaths. 



142 

310 

12 



r, • 1 Per cent, of 

Recoveries., Recoveries. 



2 

72 
26 



1.45 
19 
68.4 



Of course this table will not justify the conclusion that 68 per cent, 
of the cases of ruptured uterus in which gastrotomy is performed will 
recover, but it may fairly be taken as proving that the chances of recov- 
ery are at least three or four times as great as when the more usual prac- 
tice is adopted/ 

Porro's operation has been suggested instead of simple gastrotomy. 
In seven cases tabulated by Godson, in which this operation was per- 
formed after rupture of the uterus, the mothers all died ;^ but this 
does not prove that this plan, which adds little to the dangers of the 
case, should not be adopted. It has, at least, the advantage of effect- 
ually preventing the possibility of the recurrence of rupture in a future 
pregnancy. 

[Supravaginal hysterectomy, unless preceded by a true C?esarean sec- 
tion, has no right or title to the name of '' Porro,'^ any more than the 
same operation for a uterine fibroma has. If it is to bear the name of 
any man, it should be that of Prevot, who introduced it at Mosco\\' on 
Nov. 22, 1878. The method has two very serious objections to its 
performance : 1 , it is generally fatal in its results ; 2, we have no right 
to unsex a well-formed woman because she has had the misfortune to 
rupture her uterus, when a better result may be attained by carefully 
suturing the laceration. — Ed.] 

Lacerations of the cervix are of very common occurrence. Occa- 
sionally, after delivery, they may cause hemorrhage when the uterus 
itself is firmly contracted or secondary hemorrhage during the puerperal 
month. As a rule, they are not recognized, and it is only of late years, 
chiefly owing to the labors of Emmet, that their important influence in 
producing various chronic forms of uterine disease has been realized. 
In the large majority of cases the lacerations are lateral, either on one 
or both sides of the cervix. If they give rise to hemorrhages, the local 
a})plication of styptics is probably the best resource. Whether it is 

^American Puerperal Laparotomies. — After a senreh ot' several years I 
have thus far collected 43 cases in the Tnited States, \\\i\\ 21 women ami 2 cliildren 
saved. One mother and child were saved hv an innneduite operatimi witii a poeket- 
knife in 18()9. I presume that a iicneral record of American (Operations pul^lishe^l 
and unpuhlished would sliow a saving- of about r>0 per cent., which is nuich lower than 
that claimed by Trask and Jolly, ci>llecteil from published reports, and less than I 
thougiit myself a year ago. Take Trask's foreign cases. 20, and our own 43. ami we 
liave, native and foreign, (53, with 37 recoveries ami 2(> ileaths. I look \\\^ox\ our own 
statistics as nnich more reliable, because many of the impublished cases were searclietl 
out by correspondence. — Harris' note to fourth .Vmerican edition. 

^ A successful case lias recently been reported by Professor Slavjansky of St. Teters- 
bure-. 



446 LABOR. 

advisable to treat severe forms by the immediate application of silvei 
sutures, as recommended by Fallen/ is a subject as yet too little under- 
stood to justify the expression of an opinion. 

It is perhaps needless to say that the operation must be performed 
with the same minute care that has raised ovariotomy to its present pitch 
of perfection, and that especial attention should be paid to the sponging 
out of the peritoneum and the removal of foreign matters. 

Recapitulation.— To recapitulate, I think what has been said justi- 
fies the following rules of treatment after rupture : 

1. If the head or presenting part be above the brim and the foetus 
still m utero — forceps, turning, or cephalotripsy according. to circum- 
stances. 

2. If the head be in the pelvic cavity — forceps or cephalotripsy. 

3. If the foetus have wholly or in great part escaped into the abdom- 
inal cavity — gastrotomy. 

As to the subsequent treatment, little need be said, since in this we 
must be guided by general principles. The chief indication will be to 
remove shock and rally the patient by stimulants, etc., and to combat 
secondary results by opiates and other appropriate remedies. 

Drainage has been recommended in cases in Avhich gastrotomy has not 
been resorted to, and the results are said to have been good. Mann^ 
advises that a large piece of drainage-tube should be bent in the middle, 
at which point a free opening should be made. This bent portion is 
passed for about half an inch through the laceration ; the free ends are 
fastened together beyond the vulva and covered with an antiseptic 
dressing. After forty-eight hours the wound should be regularly irri- 
gated with 2 per cent, solution of carbolic acid. 

Lacerations of the vagina occasionally take place, and in the great 
majority of cases they are produced by instruments, either from a want 
of care in their introduction or from undue stretching of the vaginal 
walls during extraction with the forceps. Slight vaginal lacerations 
are probably much more common after forceps delivery than is generally 
believed to be the case. As a rule, they are productive of no permanent 
injury, although it must not be forgotten that every breach of continuity 
increases the risk of subsequent septic absorption. When the laceration 
is sufficiently deep to tear through the recto-vaginal septum or the 
anterior vaginal vvall, the passage of the urine or feces is apt to prevent 
its edges uniting ; then that most distressing condition, recto- vaginal or 
vesico-vaginal fistula, is established. 

It must not be supposed that fistul?e are often the result of injury 
during operative interference. That is a common but very erroneous 
opinion both among the profession and the public. In the vast majority 
of cases the fistulous opening is the consequence of a slough resulting 
from inflammation, j^roduced by long-continued pressure of the vaginal 
walls between the child's head and the bony pelvis in cases in which 
the second stage has been allowed to go on too long. In most of these 
cases instruments were doubtless eventually used, and they got the blame 
of the accident ; whereas the fault lay, not in their being employed, but 

^ Transactions of the Intern. Med. Congr., vol. iv. 
2 Centrcdblattf.'Gynak., Bd. v. S., 377\ 



RUPTURE OF THE UTERUS, ETC. 447 

rather in their not having been used scjon enough to prevent the eon- 
tusion and inflammation which ended in 3h)Ughing. 

When vesico-vaginal fistulcT are the result of lacerations during laljor, 
tlie urine must escape at once ; but this is rarely the case. In the large 
majority of cases the urine does not pass jjer vaginam until more than a 
week after delivery, showing that a lapse of time is necessary for inflam- 
matory action to lead to sloughing. In order to throw some light on 
these points, on which very erroneous views have been held, I have 
carefully examined \\\q histories, from various sources, of 63 cases of 
vesico-vaginal fistula : 

Statistical Pacts. — 1st. In 20 no instruments were employed. Of 
these there were in labor 

Under 24 hours 2 

From 24 to 48 " 8 ^ 

40 to 70 " 2 

70 to 80 " 7 

80 hours and upward 1 

20 

Therefore, out of these 20 cases one-half were certainly more than 
forty-eight hours in labor, and 6 of the remaining 10 were probably so 
also. In only 1 of them is the urine stated to have escaped per vaginam 
immediately after delivery. In 7 it is said to have done so within a 
week, and in the remainder after the seventh day. 

2d. In 34 cases instruments were used, but there is no evidence of 
their having produced the accident. Of these there were in labor 

Under 24 hours 2 

From 24 to 48 '' 8 

48 to 72 " 10 

72 hours and upward 14 

34 

The urine escaped within twenty-four hours in 2 cases only, within a 
week in 16, and after the seventh day in 15. 

So that here, again, we have the history of unduly protracted delivery, 
24 out of the 34 having been certainly more than forty-eight hours in 
labor. 

3d. In 9 cases the histories show that the production of the fistula 
may ftxirly be ascribed to the unskilled use of instruments. Of these 
there were in labor 

Under 24 liours 7 

From 24 to 48 " 1 

48 to 72 " 1 

9 

The urine escaped at once in 7 cases, and in the romainino; 2 after the 
seventh day. 

These statistics seem to me to prove in the clearest manner that in 
the large majority of oases this unhap]>y accident may be directly tr;u\Hl 
to tlie bad practice of allowing labor to drag so manv hoin-s in the 
second stage without as<^istance, and not to premature instnnnental iiuer- 

' Hut of these in 7 no precise time is stated; t) ot" tlieiu are marked vo'ij tedious; 
therefore tliey probably exeeeiied the limit. 



448 LABOR. 

ference. This question has recently been elaborately studied by Emmet, 
who gives numerous statistical tables which fully corroborate these views. 
His conclusion, the result of much practical experience of vesico-vaginal 
fistulse, is worthy of being quoted. ^^ I do not hesitate/^ he says, " to 
make the statement that I have never met with a case of vesico-vaginal 
fistula which, without doubt, could be shown to have resulted from 
instrumental delivery. On the contrary, tlie entire weight of evidence 
is conclusive in showing that the injury is a consequence of delay in 
delivery.'' ^ 

Treatment. — As to the treatment of vaginal laceration, little can be 
said. In the slighter cases vaginal injections of diluted Condy's fluid 
will be useful to lessen the risk of septic absorption, and the graver, 
when vesico-vaginal or recto-vaginal fistulae have actually formed, are 
not within the domain of the obstetrician, but must be treated surgically 
at some future date. 

[The Rational Treatment of Rupture of the Uterus. — The three 
rules given on page 446 are those found in obstetrical works of high 
authority, but are not based upon the teachings of abdominal surgery as 
shown by the results of operations recorded within a few years. Reason- 
ing from analogy and the fearful mortality of cases delivered per vias 
naturales after uterine rupture, we are forced to the conclusion that 
something more is needed than the delivery of the woman and the 
removal of the placenta if we hope to reduce the proportion of deaths, 
Avhich is very great except after laparotomy — a method of delivery 
capable of saving nearly 50 per cent. There is no objection to delivering 
the foetus by the natural channel, provided it can be readily done ; but 
we have very little reason to anticipate a favorable result if we rest our 
eiForts here. Children entirely escaped into the abdominal cavity have 
been drawn back through the rent and delivered by the vagina, and the 
women have recovered. In one well-authenticated case the woman was 
thus saved in our own country on four occasions. But we are not to 
expect such results, as a fatal issue is far more frequent than a recovery 
under such circumstances. Our object should be to save the life of the 
mother and, if at all possible, that of the foetus, and all our efforts 
should be directed to this end. AVe may console ourselves with having 
delivered the woman prior to her death, but to prevent this fatal issue 
should be our chief aim. The general impression among ovariotomists 
is, that blood is not an innocent fluid in the abdominal cavity ; and the 
remarkable results of the ojDerations of Dr. Keith of London, formerly of 
Edinburgh, are attributed to the care he exercises in preventing the second- 
ary escape of blood into the abdominal cavity. Dr. Ludwig Winckel of 
Miillheim, Germany, who performed the Csesarean operation 13 times and 
laparotomy after rupture of the uterus 4 times, Avas of the impression that 
the liquor amnii was innocuous if only a short time in contact with the 
peritoneum ; and the same may be said of blood, ovarian fluid, parova- 
rian fluid, and, to some degree, also of urine. Rupture of the bladder 
is now cured by sewing up the rent and carefully cleansing the abdom- 
inal cavity of blood and urine. But these fluids are all capable of 
setting up peritonitis, and blood by its decomposition is particularly apt 

^ The Principles and Practice of Gynaecology, p. 669. 



INVERSION OF THE UTERUS. 449 

to give rise to septic poisoning : then why let it remain in the aV^doniinal 
cavity in cases of ruptured uterus? If it is important to cleanse this 
cavity from blood and ovarian fluid in ovariotomy, and from blood and 
amniotic fluid after the Csesarean section, then why should we be content 
with delivering the foetus in cases of rupture of the uterus, when we 
know that the peritoneal cavity still contains a compound fluid which 
may destroy the woman if not removed and the parts cleansed ? AVe 
have also an additional risk in the fact that the uterine rupture may 
gape and allow the lochia to escape into the peritoneal cavity, thus pro- 
viding another element for septic poisoning. I am, then, fully per- 
suaded that in all cases of rupture, where it is evident that 1)1 ood 
and liquor amnii have escaped into the abdominal cavity, we ought 
to open the abdomen, cleanse out the cavity, and close up the rent by 
deep-seated and superficial sutures of carbolized pure silk. In cervico- 
vaginal rupture the closure of the rent may not be so important in the 
sense of safety to the woman, as there is generally a natural drainage 
into the vagina ; neither is laparotomy itself so imperatively demanded 
as in cases Avhere the fundus or body of the uterus is rent. But it 
becomes important to close the rent cervix in view of future trouble 
from ectropium and erosion. As in the Csesarean operation, promptness 
of action is all important if we hope to save the patient. I know that 
these views upon the treatment of ruptured uterus are in advance of 
those held by British obstetrical writers, but they are certainly logical 
deductions from the experience of such operators as Dr. Keith, Mr. 
Lawson Tait, and others, and from the well-known results of promptly- 
performed laparotomies in rupture accidents in the United States. The 
removal of the uterus after rupture has as yet only added to the risk, 
and I do not believe we are justified in resorting to it where there is no 
pelvic obstruction. — Ed.] 



CHAPTER XVII. 

INVERSION OF THE UTERUS. 

Inversion of the uterus shortly after the birth of the child is 
one of the most formidabk^ accidents of parturition, loading to symp- 
toms of the greatest urgency, not rarely })roving fatal, and roquiriuii- 
prompt and skilful treatment. Ilencc it has attained an unusual 
amount of attention, and there are few obstetric subjects which have 
been more carefully studied. 

Eortuuately, the acciUent is oi' great rarity. It was onlv observed 
once in upward of 190,800 deliveries at the Rotunda Hospital simv 
its foundation in 1 745, and many practitioners have conducted largv 



450 



LABOR. 



Fig. 151. 



midwifery practices for a lifetime without ever having witnessed a case. 
It is none the less needful, however, that we should be thoroughly 
acquainted with its natural histor)^ and with the best means of dealing 
with the emergency when it arises. 

Acute and Chronic Forms. — Inversion of the uterus may be met 
with in the acute or chronic form ; that is to say, it may come under 
observation either immediately or shortly after its occurrence, or not 
until after a considerable lapse of time when the involution following 
pregnancy has been completed. The latter falls more properly under 
the province of the gynecologist, and involves the consideration of 
many points that would be out of place in a work on obstetrics. Here, 
therefore, the acute form alone is considered. 

Description. — Inversion consists essentially in the enlarged and 
empty uterus being turned inside out, either partially or entirely ; and 
this may occur in various degrees, three of which are usually described 
and are practically useful to bear in mind. In the first and slightest 
degree there is merely a cup-shaped depression of the fundus (Fig. 
151); in the second the depression is greater, so that the inverted por- 
tion forms an introsusception, as it were, and projects downward through 

the OS in the form of a round ball, not un- 
like the body of a polypus, for which, in- 
deed, a careless observer might mistake it ; 
and, thirdly, there is the complete variety, in 
which the whole organ is turned inside out, 
and may even project beyond the vulva. 

The symptoms are generally very cha- 
racteristic, although, when the amount of 
inversion is small, they may entirely escape 
jf observation. They are chiefly those of pro- 
' found nervous shock — viz., fainting, small, 
rapid, and feeble pulse, possibly convulsions 
and vomiting, and a cold, clammy skin. 
Occasionally severe abdominal pain and 
bearing down are felt. Hemorrhage is a 
frequent accompaniment, sometimes to a 
very alarming extent, especially if the 
placenta be partially or entirely detached. 
The loss of blood depends to a great extent 
on the condition of the uterine parietes. If 
there be much contraction on the part that 
is not inverted, the introsuscepted part may 
be sufficiently compressed to prevent any 
^reat loss. If the entire organ be in a state of relaxation, the loss may 
be excessive. 

The occurrence of such symptoms shortly after delivery would of 
necessity lead to an accurate examination, Avhen the nature of the case 
may be at once ascertained. On passing the finger into the vagina we 
either find the entire uterus forming a globular mass — to which the 
placenta is often attached — or, if the invasion be incomplete, the vagina 
is occupied by a firm, round, and tender swelling, which can be traced 




Partial Inversion of the Fundus. 

(From a preparatiou in the Museum of 
Guy's Hospital.) 



INVERSION OF THE UTERUS. 451 

upward through the os uteri. The hand placed on the abdomen will 
detect the absence of the round ball of the contracted uterus; the 
bimanual examination may even enable us to feel the cup-shaped 
depression at the site of inversion. 

Differential Diag-nosis. — When such signs are o])served immediately 
after delivery mistake is hardly possible. Numerous instances, how- 
ever, are recorded in which the existence of inversion was not imme- 
diately detected, and the tumor formed by it only observed after the 
lapse of several days, or even longer, when the general symptoms led to 
vaginal examination. It is probable that in such cases a partial inver- 
sion had taken place shortly after delivery, which as time elapsed became 
gradually converted into the more complete variety. In a case of this 
kind, as in a chronic inversion, some care is necessary to distinguish the 
inversion from a uterine polypus, which it closely resembles. The 
cautious insertion of the sound will render the diagnosis certain, since 
its passage is soon arrested in inversion, while if the tumor be polypoid 
it readily passes in as far as the fundus. 

The mechanisni by which inversion is produced is well worthy 
of study, and has given rise to much difference of opinion. 

A very general theory is that it is caused in many cases by mis- 
management of the third stage of labor, either by traction on the cord, 
the placenta being still adherent, or by improperly applied pressure on 
the fundus, the result of both these errors being a cup-shaped depres- 
sion of the fundus which is subsequently converted into a more complete 
variety of inversion. That such causes may suffice to start the inversion 
cannot be doubted, but it is probable that their frequency has been much 
exaggerated. Still, there are numerous recorded cases in which the 
commencement of the inversion can be traced to them. Improperlv 
applied pressure (as when the whole body of the uterus is not grasped 
in the hollow of the hand, but when a monthly nurse or other unin- 
structed person presses on the lower part of the abdomen, so as simplv 
to push down the uterus en masse) is often mentioned in histories of the 
accident. Thus, in the Edinburgh Medical Journal for June, 1848-, a 
case is related in which the patient would not have a medical man, but 
was attended by a midwife, who after the birth of the child pulled on 
the cord, while the patient herself clasped her hands and pushed down 
her abdomen, at the same time straining forcibly, when the uterus became 
inverted and the patient died of hemorrhage before assistance could be 
procured. Here both of the mechanical causes alluded to were in opera- 
tion. In several cases it is mentioned that the accident occurretl while 
the nurse was compressing the abdomen. That the aivident is practicallv 
im])ossible wIumi firm and equable contraction has taken ])lace cannot be 
questioned. Hence it is of paramount importance that the practitioner 
should himself carefully attend to the conduct i>f the third stage o\^ 
labor. 

In a large proportion ol' cases no mechanical causes can be tracixl, 
and the occurrence of spontan(H>us inversion must be admitted. There 
are various theories held as to how this occurs. Partial and irregular 
contraction of the uterus is generally adn\iU(Hl to be an iniponant tacior 
in its production ; but it is still a nialter o( dispute whethei- the inver- 



452 



LABOR. 



sion is prcxliiceil mainly bv an active contraction of the fundus and 
body of the uterus, the lower poition and cervix being in a state of 
relaxation, or whether the precise reverse of this exists, the fundus 
being relaxed and in a state of quasi-paralysis, while the cervix and 
lower portion of the uterus are irregularly contracted. The former is 
the vieAT maintained by Radford and Tyler Smith, while the latter is 
upheld by Matthews Duncan. 

There are good clinical reasons for believing that Dimcan's view 
more nearly corresponds with the true facts of the case ; for if the 
fundus and body of the titerus be really in a state of active contrac- 
tion while the cer\'ix is relaxed, we have, as Duncan points out. the 
very condition which is normal and desirable after deliver^', and that 
which we do our best to produce. If, however, the opposite condition 
exist and the fundus be relaxed, while the lower ponion is spasmodic- 
ally contracted, a state exists closely allied to the so-called hour-glass 
contraction. Supposing now any cause produces a partial depression 
of the fundus, it is easy to understand how it may be grasped by the 
contracted portion and ctu'ried more and more down, in the manner of 
an iutrosusception, until complete inversion results. That such partial 
paralysis of the uterine walls often exists, es|)ecially about the placental 
site, was long ago pointed otit by Rokitansky and other pathologists. 
This theory supposes the original partial dej^ression and relaxation of 
the fundus. How this is often produced by mismanagement of the 
third stage has already been pointed out ; but even in the absence of 
such causes it may result from strong bearing-down eiforts on the part 
of the patient, or, as Duncan holds, from the absence of the retentive 
power of the abdomen. Indeed, the incompatibility of an actively con- 
tracted state of the fundus with the partial 
depression which is essential, according to 
botli views, for the pmduction of inversion 
is the strongest argument in favor of Dun- 
can's theory. 

A totally different view has more recently 
been sustained by Dr. Taylor of Xew York, 
who maintains that "spontaneous active in- 
version of the uterus rests upon prolonged 
natural and energetic action of the body and 
fundus: the cervix, the lower part, yielding 
first, is thus rolled out, or everted, or doubled 
up. as there is no obstruction from the con- 
tractilitv of the cervix, which is at rest or 
functionally paralyzed : the body is gradu- 
allv. sometimes instantaneously, forced lower 
and lower, or invene<:l." ^ That paitial inver- 
sion mav commence at the cervix was pointed 
out by JDuncan in his paper, who depicts it 
in the accompanying diagram (Fig. 152), 
and states it to be of not unfrequent occur- 
It is not impossible that occasionally such a state of things 

1 Jv'eu- York Med. Journ., 1872, vol. xv. p. 449. 



Fig. 152. 




lUustratine the Commencement 
of Inversion at the Cervix. 
(After Duncan.) 



rence. 



INVERSION OF THE UTERUS. 453 

should be carried on to complete inversion. But there are serious 
objections to the acceptance of Dr. Taylor^s view that such is the 
principal cause of inversion, since the process above described would 
be of necessity a slow and long-continued one, w^iereas nothing is more 
certain than that inversion is generally sudden and accompanied Vjy 
acute symptoms of shock, and is often attended by severe hemorrhage, 
which could not occur when such excessive contraction was taking 
place. 

The treatment of inversion consists in restoring the organ to its 
natural condition as soon as possible. Every moment's delay only serves 
to render restoration more difficult, as the inverted portion becomes 
swollen and strangulated ; whereas if the attempt at reposition be 
made immediately, there is generally comparatively little difficulty 
in effecting it. Therefore, it is of the utmost importance that no 
time should be lost and that we should not overlook a partial or in- 
complete inversion. Hence the occurrence of any unusual shock, pain, 
or hemorrhage after delivery without any readily ascertained cause 
should always lead to a careful vaginal examination. A want of atten- 
tion to this rule has too often resulted in the existence of partial inver- 
sion being overlooked until its reduction was found to be difficult or 
impossible. 

In attempting to reduce a recent inversion the inverted portion of the 
uterus should be grasped in the hollow of the hand and pushed gently 
and firmly upward into its natural position, great care being taken to 
apply the pressure in the proper axis of the pelvis, and to use counter- 
pressure by t\\Q left hand on the abdominal walls. Barnes lays stress 
on the importance of directing the pressure toward one side, so as to 
avoid the promontory of the sacrum. The common plan of endeavor- 
ing to push back the fundus first has been well shown by McClintock ^ 
to have the disadvantage of increasing the bulk of the mass that has 
to be reduced, and he advises that while the fundus is lessened in size 
by compression we should at the same time endeavor to push up first 
the })art that was less inverted — that is to say, the portion nearest the 
OS uteri. Should this be found impossible, some assistance may be 
derived from the manixntvre recommended by ]\[erriman and others, of 
first endeavoring to push up one side or wall of the uterus, and then the 
other, alternating the upward pressure from one side to the other as we 
advance. It often happens, as \.\\q hand is thus ajiplied, that the uterus 
somewhat suddenly reinverts itself, sometimes with an audible noise, 
nuicli as an India-rubber bottle would do under similar circumstances. 
When reposition has taken place the hand should be kept for some 
time in the uterine cavity to excite tonic contraction, or a stream o^ luu 
water at 110° F. may be injected, and if that fails, a weak solution o\^ 
})erchloride of iron, so as to cause tonic contraction ot' the uterus and 
thus prevent a recurrence of the accident. 

Ft is hardly necessary to ])oint out how nuu-h thos(> uKuuxnivres will 
be facilitated by placing the patiiMit fully iiiuler ilu^ intliionce o[ an 
ana\sthetic. 

There has been nuich ditference o( opini(Mi as to the niauaLivnieni oli 

^ Dist'a.^Ci^ of Womt'n, [>. 7i>. 



454 LABOE. 

the placenta in cases in which it is still attached when inversion occurs. 
Should we remove it before attempting reposition, or should we first 
endeavor to reinvert the organ and subsequently remove the placenta ? 
The removal of the placenta certainly much diminishes the bulk of the 
inverted portion, and therefore renders reposition easier. On the other 
hand, if there be much hemorrhage, as is so frequently the case, the 
removal of the placenta may materially increase the loss of blood. 
For this reason most authorities recommend that an endeavor should 
be made at a reduction before peeling oiF the after-birth. But if any 
delay or difficulty be experienced from the increased bulk, no time 
should be lost, and it is in every way better to remove the placenta 
and endeavor to reinvert the organ as soon as possible. 

Supposing we met with a case in which the existence of inversion 
has been overlooked for days, or even for a week or two, the same pro- 
cedure must be adopted ; but the difficulties are much greater, and the 
longer the delay the greater they are likely to be. Even now, how- 
ever, a well-conducted attempt at taxis is likely to succeed. Should it 
fail, we must endeavor to overcome the difficulty by continuous pressure 
applied by means of caoutchouc bags distended with water and left in 
the vagina. It is rarely that this will fail in comparatively recent 
eases, and such only are now under consideration. Tt is likely that by 
pressure applied in this way for twenty-four or forty-eight hours, and 
then followed by taxis, any case detected before the involution of the 
uterus is completed may be successfully treated. 

[Spontaneous Reposition of the Inverted Uterus. — After all 
attempts have failed to replace an inverted uterus, already too much 
contracted to yield to the pressure employed, Xature sometimes accom- 
plishes the work herself, as proved beyond question from quite a num- 
ber of well-established cases, several of which belong to our own country. 
A few years ago I saw one of the most remarkable on record. A woman 
of twenty-nine, mother of three children, miscarried at six and a half 
months from lifting. From the time of her delivery she was subject 
to weepings of blood, and at times to more or less severe hemorrhages, 
one of the last of which nearly proved fatal. This condition of dis- 
ease had lasted three years, when Dr. Walter F. Atlee was called in to 
relieve her in her worst hemorrhagic attack, and found her uterus in- 
verted, and a nodular growth upon the fundus which gave out an offen- 
sive odor. Thinking the disease possibly malignant, and believing, in 
any ev^ent, that to save the woman he would be obliged to remove the 
uterus, he called a consultation and ])repared for the operation ; but 
when the patient was etherized, placed in the knee-elbow position, and 
Sims' speculum introduced, behold, there was nothing to be seen in 
the vagina but a soft dilated cervix, the uterus having been replaced 
by atmospheric pressure, aided perhaps by traction on the uterine at- 
tachments within. AVhen explored, the uterus was found to be very 
soft and thin, and to contain some hard nodular masses, which on 
removal proved to be portions of an adherent placenta. The hemor- 
rhage ceased upon the reposition and cleaning out of the uterus, and 
the patient made a good recovery. She has been again pregnant. 

This woman was anaemic to a marked degree, and her abdominal 



INVEESIO^ OF THE UTERUS. 4oo 

walls so thin that a finger in the uterus could readily be felt above the 
pubes. There is not the slightest doubt about the inversion, which was 
proved to exist a short time before the change of posture by Prof. 
Agnew, who made a finger in the rectum meet another above the pubes, 
and there was no fundus between them. 

Two ^ cases are uj^on record where reposition was the result of falls, 
one at eight months and the other aftei' as many years. Drs. M^jehring, 
C D. Meigs, H. L. Hodge, and Warrington of this city failed to re- 
place a uterus, and the woman again became pregnant in about six 
years, aborting with a three months' foetus under the care of Dr. War- 
rington. Dr. Meigs saw a second case with Dr. Levis, in which there 
was violent flooding followed by hemorrhages, which gradually de- 
clined. After her return from a journey AVest she became pregnant 
and bore a child. Dr. John L. Atlee of Lancaster failed to replace 
the uterus of a woman, but she recovered spontaneously and bore a 
child a year afterward.^ Dr. Johnson F. Hatch of Kent, Connecticut, 
reported a case in a letter to Dr. C. D. Meigs in which inversion 
occurred spontaneously fourteen or fifteen hours after labor. After 
being under the care of several physicians, she had, at the end of eigh- 
teen months, two severe hemorrhagic attacks, after which she improved, 
and finally, at the end of two years and nine months, bore a child of 9 
pounds and 6 ounces. 

In all cases spontaneous reposition appears to result from a softening 
and thinning of the uterine walls as the result of anaemia brought on 
by hemorrhages. This was particularly noticed by Boivin and Duges 
in autopsies of women dying of repeated hemorrhages. — Ed.] 

[^ See Daillez, Essai sur le Renversement de la 3fatrice, Paris, 1805, pp. 105-107.] 
[2 Meigs' Obstetrics, 1852, Philada., p. 608.] 



PART IV. 

OBSTETRIC OPERATIOXS. 



CHAPTER I. 

INDUCTION OF PKEMATUEE LABOR. 

History of the Operation. — The first of the obstetric operations we 
have to consider is the induction of premature labor — an oj^eration 
which, like the use of .forceps, was first suggested and practised in 
England, and the recognition of which, as a legitimate procedure, we 
also chiefly owe to the labor of English obstetricians, in spite of much 
opposition both at home and abroad. It is not known with certainty to 
whom we owe the original suggestion, but we are told by Denman that 
in the year 1756 there was a consultation of the most eminent physi- 
cians at that time in London to consider the advantages which might 
be expected from the operation. The proposal met with formal approval, 
and was shortly after carried into practice by Dr. Macaulay, the patient 
being the wife of a linen-draper in the Strand. From that time it has 
flourished in Great Britain, the sphere of its application has been largely 
increased, and it has been the means of saving many mothers and chil- 
dren who would otherwise, in all probability, have perished. On the 
Continent it was long before the operation was sanctioned or practised. 
Although recommended by some of the most eminent German prac- 
titioners, it was not actually performed until the year 1804. In 
France the opposition was long-continued and bitter. ]\Iany of the 
leading teachers strongly denounced it, and the Academy of iledicine 
formally discountenanced it so late as the year 1827. The objections 
were chiefly based on religious grounds, but partly, no doubt, on mis- 
taken notions as to the object proposed to be gained. Although fre- 
quently discussed, the operation was never actually carried into practice 
until the year 1831, when Stoltz performed it with success. Since that 
time opposition has greatly ceased, and it is now employed and highly 
recommended Idv the most distinguished obstetricians of the French 
scliools. 

Objects of the Operation. — In inducing premature labor we pro- 
pose to avoid or lessen the risk to which in certain cases the mother is 
exposed by delivery at term, or to save the life of the child, which 
might otherwise be endangered. Hence the operation may be indicated 
either on account of the mother alone or of the child alone, or, as not 
unfrequently happens, of both together. 

456 



INDUCTION OF PREMATURE LABOR. 457 

In by far the largest numl^er of cases the operation is performed on 
account of defective proportion between the child and the maternal 
passages, due to some abnormal condition on the part of the mother. 
This want of proportion may depend on the presence of tumors either 
of the uterus or growing from the pelvis. But most frequently it 
arises from deformity of the pelvis (p. 404), and it is needless to repeat 
what has been said on that i)oint. I shall therefore only briefly refer 
to a few more uncommon causes which occasionally necessitate its per- 
formance. 

One of these is an habitually large or over-firmly ossified foetal head. 
Should we meet with a case in which the labors are always extremely 
difficult and the head apparently of unusual size, although there is no 
apparent want of space in the pelvis, the induction of labor would be 
perfectly justifiable, and in all probability would accomplish the desired 
object. In such cases the full period of delivery would require to be 
anticipated by a very short time. A week or a fortnight might make 
all the difference between a labor of extreme severity and one of com- 
parative ease. 

There is a large class of cases in which the condition of the mother 
indicates the operation. Many of these have already been considered 
when treating of the Diseases of Pregnancy. Amongst them may be 
mentioned vomiting which has resisted all treatment, and which has. 
produced a state of exhaustion threatening to prove fatal ; chorea, albu- 
minuria, convulsions, or mania ; excessive anasarca, ascites, or dyspnoea 
connected with disease of the heart, lungs, or liver, which may be, in a 
great measure, caused by the pressure of the enlarged uterus ; in fact, 
any condition or disease affecting the mother, provided only we are con- 
vinced that the termination of pregnancy would give the patient relief, 
and that its continuance would involve serious danger. It need hardly 
be pointed out that the induction of labor for any such causes invoh'es 
grave responsibility, and is decidedly open to abuse : no practitioner 
would, therefore, be justified in resorting to it — especially if the child 
have not reached a viable age — without the most anxious consideration. 
No general rules can be laid down. Each case must be treated on its 
own merits. It is obvious that the nearer the patient is to the full period, 
the greater will be i\\G chance of the child surviving, and the less hesita- 
tion need then be felt in consulting the interest of tlie mother. 

In another class of cases the operation is indicated by circumstances 
affecting the life of the child alone. Of these the most common are 
those in which the child dies, in several successive jiregnancies, before 
the termination of utero-gestation. This is generally the result of fattv, 
calcareous, or syphilitic degeneration of the placenta, which is thus ren- 
dei-ed incapable of performing its functions. These changes in the pla- 
centa st'ldom commence initil a comparatively advanced })eriod o( preg- 
nancy ; so that if labor be somewhat hast(^ned we may liope to enabU^ 
the patient to give birth to a living and healthy child. I'he experientn? 
of the mother will indicate the [)eri(Hl at which the death of the tortus 
has formerly taken plaiv, as she would then have apprci'iated a ditVer- 
ence in her sensations, a diminution in the vigor ot' the tonal nune- 
ments, a sense of weight and coldnes>, and similar si^ns. For >ome 



458 OBSTETRIC OPERATIONS. 

weeks before the time at Avhich this chaDge has been experienced we 
should carefully auscultate the foetal heart from day to day, and in most 
cases the approach of danger will be indicated, sufficiently soon to 
enable us to interfere with success, by tumultuous and irregular pulsa- 
tions or a failure in their strength and frequency. On the detection 
of these, or on the mother feeling that the movements of the child are 
becoming less strong, the operation should at once be performed. 
Simpson also induced premature labor with success in a patient who 
had twice given birth to hydrocephalic children. In the third preg- 
nancy, which he terminated before the natural period, the child was 
well- formed and healthy. 

Some obstetricians have proposed to induce labor with the view of 
saving the child when the mother was suffering from mortal disease. 
This indication is, however, so extremely doubtful from a moral point 
of view that it can liardly be considered as ever justifiable. 

Various Methods of Inducing* Labor. — The means adopted for the 
induction of labor are verv numerous. Some of them act through the 
maternal circulation, as the administration of ergot and other oxytocics ; 
others by their power of exciting reflex action, or by interfering with 
the integrity of the ovum, or by a combination of both, as the vaginal 
douche, separation of the membranes from the uterine Avails, puncture 
,of the ovum, dilatation of the os, stimulating euemata, or irritation of 
the breasts. The former class are never employed in modern obstetric 
practice. Of the latter, some offer special advantages in particular 
cases, but none are equally adapted for all emergencies. Often a com- 
bination of more methods than one will be found most useful. I shall 
mention the various methods in use, and discuss briefly the relative 
advantages and disadvantages of each. 

Puncture of Membranes. — The evacuation of the liquor amnii by 
the puncture of the membranes was the first method practised, and was 
that recommended by Denman and all the earlier writers. It is the 
most certain which can be employed, as it never fails, sooner or later, 
to induce uterine contractions. There are however, several disadvan- 
tages connected with it wdiic^h are sufficient to contraindicate its use in 
the majority of cases. It is uncertain as regards the time taken in 
producing the desired effect, pains sometimes coming on within a few 
hours, but occasionally not until several days have elapsed. The con- 
tracting walls of the uterus press directly on the body of the child, 
which, being frail and immature, is less able to bear the pressure than 
at the full period of pregnancy. Hence it involves great risk to the 
foetus. Besides, the escape of the water does away with the fluid 
wedge so useful in dilating the os, and should version be necessary 
from malpresentation — a complication more likely to occur than in 
natural labor — the operation would have to be performed under very 
unfavorable conditions. These objections are sufficient to justify the 
ordinary opinion that this procedure should not be adopted unless other 
means have been tried and failed. Every now and then cases are met 
Avith in which it is extremely difficult to arouse the uterus to action, 
and under such circumstances, in spite of its drawbacks, this method 
will be found to be very valuable. When the operation has to be 



INDUCTION OF PREMATURE LABOR. 459 

performed before the child is viable — that is, before the seventh 
month — these objections do not hold, and then it is the simplest and 
readiest procedure we can adopt. Indeed, in producing early abortion 
no other is practicable. The operation itself is most simple, requiring 
only a quill, stiletted catheter, or other suitable instrument to be 
passed up to the os, carefully guarded by the fingers of the left hand 
previously introduced, and to be pressed against the membranes until 
perforation is accomplished. Meissner of Leipsic has proposed as a 
modification of this plan that the membranes should be punctured 
obliquely three or four inches above the os, so as to admit of a gradual 
and partial escape of the amniotic fluid, thus lessening the risk to the 
child from pressure by the uterus. For this purpose he employed a 
curs^ed silver canula containing a small trocar, which can be projected 
after introduction. The risk of injuring the uterus by such an instru- 
ment would be considerable, and we have other and better means at 
our command which render it unnecessary. When we require to pro- 
duce early abortion, it would be well not to attem])t to puncture the 
membranes with a sharp-pointed instrument. The object can be 
effected with certainty and greater safety by passing an ordinary 
uterine sound through the os and turning it round once or twice. 

Administration of Oxytocics, — The administration of ergot of 
rye, either alone or combined with borax and cinnamon, has been 
sometimes resorted to. This practice has been principally advocated 
by Ramsbotham, who was in the habit of exhibiting scruple doses of 
the powdered ergot every fourth hour until delivery took place. Some- 
times he found that as many as thirty or forty doses were required to 
effect the object; occasionally labor commenced after a single dose. 
Finding that the infantile mortality was very great when this method 
was followed, he modified it, and administered two or three doses only, 
and if these proved insufficient he punctured the membranes. There 
can be no doubt that ergot possesses the power of inducing uterine con- 
tractions. The risk to the child is, however, quite as great as when the 
membranes are punctured ; for not only is it subject to injurious pressure 
fi'om the tumultuous and irregular contractions which the ergot pro- 
duces, but the drug itself, when given in large doses, seems to exert 
a poisonous influence on the foetus. For these reasons ergot may 
properly be excluded from the available means of inducing labor. 

Methods Acting- Indirectly on the Uterus. — Various methods 
have IxHMi reconunended which act indirectly on the uterus, the scnuve 
of irritation being at a distance. Thus, D'Outrepont used frequently 
re})eated abdominal frictions and tight bandages. Si'anzoni, remem- 
bering the intimate connection between the mamuKv and uterus, and 
the tendency which irritation of the former has to induce contraction 
of the latter, recomuiended the frequent application ot' cupping-glasses 
to the breasts. Radtbrd and others have employed galvanism. Stim- 
ulating enemata have been enq>loved. All tlu\<e methods have oiva- 
sionally proved suecessCul, and, ludike the Ibi-imn- plans we have 
mentioned, they are not attended by any special risk to the child. 
They are, however, nuich too uncertain to bi> relied on, besiiK^< being 
irksome both io the patient and practitioner. 



460 OBSTETRIC OPERATIONS. 

The artificial dilitation of the os uteri in imitation of its natural 
opening in labor was first practised by Kliige. He was in the habit of 
passing w^ithin the os a tent made of compressed sponge, and allowing 
it to dilate by imbibition of fluid. If labor were not provoked within 
twenty-four hours he removed it and introduced one of larger dimen- 
sions, changing it as often as was necessary until his object was accom- 
plished. Although this operation seldom failed to induce labor, it had 
the disadvantage of occupying an indefinite time, and the irritation 
produced was often painful and annoying. Dr. Keiller of Edinburgh 
was the first to suggest the use of caoutchouc bags distended by air as a 
means of dilating the os. This plan has been perfected by Dr. Barnes 
in his well-kno^vn dilators, which are of great use in many cases in 
which artificial dilatation of the cervix is necessary. They consist of a 
series of India-rubber bags of various sizes, with a tube attached (Fig. 153) 
through which water can be injected by an ordinary Higgiuson's syringe. 
They have a small pouch fixed externally in which a sound can be 
placed, so as to facilitate their introduction. When distended with 
water the bags assume somewhat of a fiddle shape, bulging at both 
extremities, which ensures their being retained within the os. When 
first introduced into practice as a means of inducing labor it was thought 
that this method gave a complete control over the process, so that it 
could be concluded within a definite time at the will of the operator. 
The experience of those who have used it much has certainly not justi- 
y ^ ^,, fied this anticipation. It is true that occasionally con- 

tractions intervene within a few hours after dilatation 
has been commenced, but, on the other hand, the uterus 
often responds very imperfectly to this kind of stim- 
ulus, and the bags may be inserted for many consecu- 
tive hours without the desired result supervening, the 
puncture of the membranes being eventually necessary 
in order to hasten the process. Indeed, my own expe- 
rience would lead me to the conclusion that as means of 
evoking uterine contraction cervical dilatation is very 
unsatisfactory. Dr. Barnes himself has evidently seen 
reason to modify his original views, for while he at 

f first talked of the bags as enabling us to induce labor 

with certainty at a given time, he has since recommended 
that uterine action should be first provoked by other 
Barnes Bag for nieaus, the dilators being subsequently used to accele- 
Diiatiiig the pate the labor thus brought on. The bags thus employed 
find, as I believe, their most useful and a very valuable 
application ; but when used in this way they cannot be considered as 
a means of originating uterine action. A subsidiary objection to the 
bags is the risk of displacing the presenting part. I have, for example, 
introduced them when the head was presenting, and on their removal 
found the shoulder lying over the os. It is not difficult to understand 
how the continuous pressure of a distended bag in the internal os might 
easily push away the head, Avhich is so readily movable so long as the 
membranes are unruptured. Still, if labor be in progress and the os 
insufficiently dilated, the possibility of this occurrence is not a suflicient 




INDUCTION OF PREMATURE LABOR. 461 

reason for not availing ourselves of the undoubtedly valuable assistance 
which the dilators are capable of giving. 

Separation of the Membranes. — Some processes for inducing labor 
act directly on the ovum by separating the membranes to a greater or 
less extent from the uterine walls. The first procedure of the kind was 
recommended by Dr. Hamilton of Edinburgh, and consisted in the 
gradual separation of the membranes for one or two inches all round 
the lower segment of the uterus. To reach them the finger had to be 
gently insinuated into the interior of the os, which was gradually dilated 
to a sufficient extent by a series of successive operations repeated at 
intervals of three or four hours. When this had been accomplished 
the forefinger was inserted and swept round between the membranes 
and the uterus, but it was frequently found necessary to introduce the 
greater part of the hand to effect the object; and sometimes even this was 
not sufficient, and a female catheter or other instrument had to be used 
for the purpose. The method was generally successful in bringing on 
labor, but it now and then failed, even in Dr. Hamilton's hands. It is 
certainly based on correct principles, but it is tedious and painful both 
to the practitioner and the patient, and very uncertain in its time of 
action. For these reasons it has never been much practised. 

Vag-inal and Uterine Douches. — In the year 1 836, Kiwisch sug- 
gested a plan which from its simplicity has met with much approval. 
It consists in projecting at intervals a stream of warm or cold water 
against the os uteri. Its action is doubtless complex. Kiwisch himself 
believed that relaxation of the soft parts through the imbibition of 
water was the determining cause of labor. Simpson found that the 
method failed unless the water mechanically separated the membranes 
from the uterine walls. Besides this effect, it probably directly induces 
reflex action by distending the vagina and dilating the os. In using it, 
it has been customary to administer a douche twice daily, and more 
frequently if rapid effects be desired. The number required varies in 
different cases. The largest number Kiwisch found it necessary to use 
was seventeen, the smallest five. The average time that elapses before 
labor sets in is four days. Hence the method is obviously useless when 
ra])id delivery is required. 

Dr. Cohen of Hamburg introduced an important modification o^ the 
process which has been considerably practised. It consists in passing a 
silver or gum-elastic catheter some inches within the os, between the 
membranes and the uterine walls, and injecting the fluid through it 
directly into the cavity of the uterus. He used creasote or tar- water, 
and injected without stopping until the patient conq^lained yy^ a feeling 
of distension. Others have found the plan equally efficacious when tliey 
only enq)loyed a small quantity of plain water, sucii as seven ov eight 
ounces. Professor La/tirewitch of St. Petersburg is a strong advocate 
of this method. Ife believes that uterine action is evoked nuu'h more 
ra])idly and certainly if the water be injected near the t'undns, and he 
has contrived an instrunient foi' the purpose with a Kmio- metallic nozzle. 

Dangers of these Plans. — So many fatal cases havt^ followed these 
methods that it cannot be doubted that, in spite i>t' their certainty and 
simplicity, there is an element oi' risk in them that shonKl not be over- 



462 OBSTETRIC OPEEATIOXS. 

looked. ^lanv of these are recorded in Barnes' work, and he comes to 
the conckision, which the facts unquestionably justify, that "the douche, 
whether vaginal or iutra-uteriue, ought to be absolutely condemned as a 
means of inducing labor," The precise reason of the danger is not very 
obvious. Sudden stretching of the uterine walls, producing shock, has 
been supposed to have caused it; but in many of the fatal cases the 
symptoms have been rather those attending the passage of air into the 
veins, and it is easy to understand how air may have been introduced 
in this way into the large uterine sinuses. 

Simpson and Scanzoni have both tried with success the injection of 
carbonic-acid gas into the vagina. Fatal results have, however, fol- 
lowed its employment, and Simpson has expressed an opinion that the 
experiment should not be repeated. 

Simpson originally induced labor by passing the uterine sound within 
the OS and up toward the fundus, and, when it had been inserted to a 
sufficient extent, moving it slightly from side to side. He Avas led to 
adopt this procedure in the belief that we might thus closely imitate the 
separation of the decidua which occurs previous to labor at term. 
Uterine contractions were induced with certainty and ease, but it was 
found impossible to foretell what time miglit elapse between the com- 
mencement of labor and the operation, which had frequently to be 
performed more than once. He subsequently modified this procedure 
by introducing a flexible male catheter without a stilette, which he 
allowed to remain in the uterus until contractions were excited. This 
plan is much used in Germany, and is now that which is also most 
frequently adopted in England. It is simple and very efficacious, 
jDains coming on almost invariably within twenty-four hours after the 
catheter or bougie is introduced. A theoretical objection is the ])ossi- 
bility of the catheter separating a portion of the placenta and giving 
rise to hemorrhage ; but in practice this has not been found to occur, 
and the risk might generally be avoided by introducing a catheter at a 
distance from the placenta, the probable situation of which has been 
ascertained by auscultation. The more deeply the catheter is introduced, 
the more certain and rapid is its efl^ect, and not less than seven inches 
should be pushed up within the os. It is not always easy to insert it so 
fai\, especially if a flexible catheter be used, which is apt to be too pliable 
to pass upward with ease. A solid bougie — male urethral bougie — 
should therefore be employed, and I have found its introduction greatly 
facilitated by anaesthetizing the patient and passing the greater part of 
the hand into the vagina. In this way it can be pushed in very gently 
and without any risk of injury to the uterus. There is some chance of 
ru])turing the membranes while pushing it upward. This accident, 
indeed, cannot always be avoided, even when the greatest care is taken ; 
but when it occurs the puncture A\ill be at a distance from the os, so 
that a small portion only of the liquor amnii will escape, and this can 
scarcely be considered a serious objection. It is always an advantage to 
allow the pains to come on gradually and in imitation of natural labor. 
Therefore, if, after the bougie has been inserted for a sufficient time, 
uterine contractions come on sufficiently strongly, we may leave the case 
to l)e terminated naturally, or if they be comparatively feeble we may 



INDUCTION OF PREMATURE LABOR. 463 

resort to accelerative procedures — viz. dilatation of the cervix in- the 
fluid bags, and subsequently the ])uncture of the membranes. Jn this 
way we have the labor completely under control; and I believe this 
method will commend itself to those who have experience of it as the 
simplest and most certain mode of inducing labor yet known, and the 
one most closely imitating the natural process. Of late I have been in 
the habit of combining dilatation of the cervix with this method by 
means of a well-carbolized sponge tent passed into the cervix after the 
bougie is in ])osition. In ten or twelve hours, when the tent and Ijougie 
are removed, the cervix is found well dilated and ready for the passage 
of the child. 

It should not be forgotten that the child is immature, and that 
unusual care is likely to be required to rear it successfully. We should 
therefore be careful to have at hand all the usual means of resuscita- 
tion ; and, as the mother may not be able to nurse at once, it would be 
a good precaution to have a healthy wet-nurse in readiness. 

[The most serious objection to the induction of premature labor is 
the frightful infantile mortality : that of the mothers is quite low in 
skilful hands. The late Dr. Cesare Belluzzi of Bologna recorded 112 
cases, with 8 deaths of women and 15 of the foetuses — 42 patients were 
treated in his private practice, and 70 in the Maternity of Bologna. In 
9 patients labor was induced because of disease in the mother ; in 1 it 
was brought on because the foetus had usually died in the ninth month 
of former })regnancies ; and in 102 the pelvis was contracted. Of these 
102, 6 died — 3 out of 38 in private practice, and 3 out of 64 in the 
hospital. Of the 9 women operated upon because of serious disease, 7 
recovered. 35 out of 42 infants were delivered alive in private prac- 
tice, and 62 out of 70 in the Maternity. The prolonged vitality of the 
foetus is largely dependent upon the period in gestation which is chosen 
for the operation ; the later the delivery, the better is the prospect of 
ultimate safety. But a small proportion of the children reach matur- 
ity. Of 32 delivered alive in hospital in a period of less than ten 
years under Dr. Belluzzi, 27 were dead before the expiration of the first 
year, and 29 in all within two years of birth. Dr. Ijudwig AVinckel 
of Miilheim, Germany, has published a record of 25 deliveries in women 
who were all the subjects of contraction of the pelvis. These patients 
all recovered: 14 children were still-born and 13 were living; of the 
latter, only 7 were alive at the end of two weeks. With the ^'cov- 
veuse^' of Auvard much better results in saving fcetal life in materni- 
ties ought now to be attained. — Ed.] 



464 OBSTETRIC OPERATIONS. 



CHAPTER II. 

TURNING. 

History of the Operation. — Turning — by which we mean the alter- 
ation of the position of the foetus and the substitution of some other 
portion of the body for that originally presenting — is one of the most 
important of obstetric operations, and merits careful study. It is also 
one of the most ancient, and was evidently known to the Greek and 
Roman physicians. Up to the fifteenth century cephalic version — that 
in which the head of the foetus is brought over the os uteri — was almost 
exclusively practised, when Pare and his pupil Guillemeau taught the 
propriety of bringing the feet down first. It was by the latter physi- 
cian especially that the steps of the operation were clearly defined ; and 
the French have undoubtedly the merit both of perfecting its perform- 
ance and of establishing the indications which should lead to its use. 
Indeed, it was then much more frequently performed than in later times, 
since no other means of effecting artificial delivery Avere known which 
did not involve the death of the child ; and practitioners doubtless 
acquired great skill in its performance, and were inclined to overrate its 
importance and extend its use to unsuitable cases. An opposite error 
was fallen into after the invention of the forceps, which for a time led 
to the abandonment of turning in certain conditions for which it was 
well adapted, and in which it has only of late years been again prac- 
tised. 

Cephalic version has, since Pare wrote, been recommended and 
practised from time to time, but the difficulty of performing it satis- 
factorily was so great that it never became an established operation. 
Dr. Braxton Hicks has perfected a method by which it can be accom- 
plished with greater ease and certainty, and which renders it a legiti- 
mate and satisfactory resort in suitable cases. To him we are also 
indebted for introducing a method of turning without passing the entire 
hand into the cavity of the uterus, which under favorable circumstances 
is not only easy of performance, but deprives the operation of one of 
its greatest dangers. 

The possibility of effecting version by external manipulation has been 
long known, and was distinctly referred to and recommended by Dr. 
John Pechey ^ so far back as the year 1698. Since that time it has been 
strongly advocated by Wigand and his followers ; and various authors 
in England, notably Sir James Simpson, have referred to the advantage 
to be derived from external manipulation assisting the hand in the inte- 
rior of the uterus. In 1854, Dr. Wright of Cincinnati advocated the 
application of the bimanual method in arm and shoulder presentations, 
chiefly w^ith the view of effecting cephalic version. To Dr. Hicks, 

^ The Complete Mididfe^s Practice, p. 142. 



TURNING. 465 

however, incontestably belongs tlie merit of having been the first dis- 
tinctly to show the possibility of effecting complete version in all cases 
in which the operation is indicated by combined external and internal 
manipulation, of laying down definite rules for its practice, and for thus 
popularizing one of the greatest improvements in modern midwifery. 

The operation is entirely dependent for success on the fact that the 
child in utero is freely movable, and that its position may be artificially 
altered with facility. As long as the membranes are unruptured and 
the foetus is floating in the surrounding fluid medium it is liable to con- 
stant changes in position, as may be readily demonstrated in the latter 
months of pregnancy, and the operation under these circumstances may 
be performed with the greatest facility. Shortly after the liquor amnii 
has escaped there is still, as a rule, no great difficulty in eflecting ver- 
sion, but as the body is no longer floating in the surrounding liquid its 
rotation must necessarily be attended with some increased risk of injury 
to the uterus. If the liquor amnii has been long evacuated and the 
muscular structure of the uterus be strongly contracted, t\\Q foetus may 
be so firmly fixed that any attempt to move it is surrounded with the 
greatest difficulties, and may even fail entirely, or be attended with such 
risks to the maternal structures as to be quite unjustifiable. 

Version may be required either on account of the mother or child 
alone, or it may be indicated by some condition imperilling both and 
rendering immediate delivery necessary. The chief cases in which it 
is resorted to are those of transverse presentation, where it is absolutely 
essential ; accidental or unavoidable hemorrhage ; certain cases of con- 
tracted pelvis ; and some complications, especially prolapse of the funis. 
The special indications for the operation have been separately discussed 
under these subjects. 

Statistics and Dangers of the Operation. — The ordinary statisti- 
cal tables cannot be depended on as giving any reliable results as to the 
risks of the operation. Taking all cases together. Dr. Churchill esti- 
mates the maternal mortality at 1 in 16, and the infantile as 1 in 3. 
Like all similar statistics, they are open to the objection of not dis- 
tinguishing between the results of the operation itself and of the cause 
which necessitated interference. Still, they are sufficient to show that 
the operation is not free from grave hazards, and that it must not be 
undertaken without due reflection. The principal dangers will be dis- 
cussed as we proceed. It may suffice to mention here that those to the 
mother must vary with the period at which the operation is undertaken. 
If version be performed early, before the rupture of the membranes, 
or, in favorable cases, without the introduction of the hand into the 
interior of the uterus, the risk must of coiu'se be infinitely less than 
in those more formidable cases in which the waters have long escaped 
and the hand and arm have to be passed into an irritable and con- 
tracted uterus. But even in the most unfavorable cases acvidents inav 
be avoided if the operator bear constiuitly in mind that the princi- 
pal danger consists in laceration of the uterus or vagina from undue 
force being employed oV from the hand and arm not beino- intrcxhiced 
in the axis of the passages. There is no operation in which gentleness, 
absence of all hiu-ry, and complete presence of mind are so essential. 
no 



466 OBSTETRIC OPERATIONS. 

A certain number of cases end fatally from shock or exhaustion or 
from subsequent complications. As regards the child the mortality 
is little, if at all, greater than in original breech and footling presen- 
tations. Xor is there any good reason why it should be so, seeing that 
cases of turning after the feet are brought through the os are virtually 
reduced to those of feet presentation, and that the mere version, if 
effected sufficiently soon, is not likely to add materially to the risk to 
which the child is exposed. 

The possibility of effecting version by external manipulation has 
been recognized by various authors, and was made the subject of an 
excellent thesis by AYigand, who clearly described the manner of per- 
forming the operation. In spite of the manifest advantages of the 
procedure, and the extreme facility with which it can be accomplished 
in suitable cases, it has by no means become the established custom to 
trust to it, and probably most practitioners have never attempted it, 
even under the most favorable conditions. The possibility of the 
operation is based on the extreme mobility of the foetus before the 
membranes are ruptured. After the waters have escaped the uterine 
walls embrace the foetus more or less closely, and version can no longer 
be readily performed in this manner. 

It may therefore be laid down as a rule that it should only be 
attempted when the abnormal position of the foetus is detected before 
labor has commenced, or in the early stage of labor, when the mem- 
branes are unruptured. It is also unsuitable for any but transverse 
presentations, for it is not meant to effect complete evolution of the 
foetus, but only to substitute the head for the upper extremity. It is 
useless whenever rapid delivery is indicated, for after the head is 
brought over the brim the conclusion of the case must be left to the 
natural powers. 

The manner of detecting the presentation by palpation has been 
already described (p. 127), and the success of the operation depends 
on our being able to ascertain the positions of the head and breech 
through the uterine walls. Should labor have commenced and the os 
be dilated, the transverse presentation may be also made out by vaginal 
examination. Should the abnormal presentation be detected before 
labor has actually begun, it is in most cases easy enough to alter it and 
to bring the foetus into the longitudinal axis of the uterine cavity. 
Pinard ^ recommends that after this has been done the foetus should be 
maintained in position by a well-fitting elastic abdominal belt. It is 
seldom, however, discovered until labor has commenced, and even if 
it be altered the child is extremely apt to resume in a short time the 
faulty position in which it was formerly lying. Still, there can be no 
harm in making the attempt, since the operation itself is in no way 
painfid, and is absolutely without risk either to the mother or child. 
^Yhen the transverse presentation is detected early in labor, I believe 
it is good practice to endeavor to remedy it by external manipulation, 
and if it fail we may at once proceed to other and more certain methods 
of operating. The procedure itself is abundantly simple. The patient 
is placed on her back, and the position of the foetus ascertained by pal- 

^ De la Version par Maneiivres externes, Paris, 1878. 



TURNING. Ai)l 

pation as accurately as possible, in the manner already described. Tlie 
palms of the hands being then ])laced over the opposite poles of the 
foetus, by a series of gentle gliding movements the head is pushed 
toward the pelvic brim, while the breech is moved in the opposite 
direction. The facility with which the foetus may sometimes be 
moved in this w^ay can hardly be appreciated by those who have 
never attempted the operation. As soon as the change is effected the 
long diameters of the foetus and the uterus will correspond, and vaginal 
examination will show that the shoulder is no longer presenting and that 
the head is over the pelvic brim. If the os be sufficiently dilated and 
labor in progress, the membranes should now l)e punctured and the 
position of the foetus maintained for a short time by external pressure, 
until we are certain that the cephalic presentation is permanently estalj- 
lished. If labor be not in progress, an attempt may at least be made 
to effect the same object by pads and a binder, one pad being placed on 
the side of the uterus in the situation of the breech, and another on the 
opposite side in the situation of the head. 

On account of the difficulty of performing cephalic version in the 
manner usually recommended, it has practically scarcely been attempted, 
and with the exception of some more recent authors it is generally con- 
demned by writers on systematic midwifery. Still, the operation off el's 
unquestionable advantages in those transverse presentations in which 
rapid delivery is not necessary, and in which the only object of inter- 
ference is the rectification of malposition ; for if successful the child 
is spared the risk of being drawn footling through the pelvis. The 
objections to cephalic version are based entirely on the difficulty of 
performance; and, undoubtedly, to introduce the hand within the 
uterus, search for, seize, and afterward place the slippery head in the 
brim of the pelvis, could not be an easy process, even under the most 
favorable circumstances, and must always be attended with considerable 
risk to the mother. Velpeau, who strongly advocated the oj)eration, 
was of opinion that it might be more easily accomplished by pushing 
up the presenting part than by seizing and bringing down the head. 
Wigand more distinctly pointed out that i\\Q head could be brought to 
a proper position by external manipulation, aided by the fingers of one 
hand within the vagina. Braxton PTicks has laid down clear rules for 
its performance, which render cephalic version easy to accomplish under 
favorable conditions, and will doubtless cause it to become a recognized 
mode of treating malpositions. The number of cases, however, in 
which it can be performed must always be limited, since, as in turn- 
ing by external mani})ulation alone, it is necessary that the liquor 
aninii should be still retained or at least have only recently escajKnl ; 
that i\\(}. presentation be freely movable about the pelvic brim : and 
that there be no necessity for ra}>id delivery. Dr. Hicks does nor 
believe protrusion of the arm to be a contraindication, and advises 
that it should be carefully replaced within the uterus. AMien, ht>w- 
cver, ])rotrnsion of the arm has occurred, the thorax is so consiantlv 
pushed down into the 'pelvis tliat re}>lacenient can neither be s;ito nor 
})racticable, except under unusually tavorablo conditions, and jKHlalic 
version will be necesv^arv. 



468 OBSTETRIC OPERATIOXS. 

Method of Performance. — It is impossible to describe the method 
of performing cephalic version more concisely and clearly than in Dr. 
Hicks' own words. '' Introduce/' he says, " the left hand into the 
vagina, as in podalic version ; place the right hand on the outside of 
the abdomen, in order to make out the position of the foetus and the 
direction of its head and feet. Should the shoulder, for instance, pre- 
sent, then push it wdth one or two fingers in the direction of the feet. 
At the same time pressure with the other hand should be exerted on 
the cephalic end of the child. This w-ill bring the head down to the 
OS ; then let the head be received on the tips of the two inside fingers. 
The head will play like a ball between the two hands ; it will be under 
their command, and can be placed in almost any part at will. Let the 
head then be placed over the os, taking care to rectify any tendency to 
face presentation. It is as well, if the breech will not rise to the fundus 
readily, after the head is fairly in the os to withdraw the hand from the 
vagina, and with it press up the breech from the exterior. The hand 
w^hich is retaining gently the head from the outside should continue 
there for some little time, till the pains have ensured the retention of 
the child in its new position and the adaptation of the uterine w^alls to 
its new form. Should the membranes be perfect, it is advisable to 
rupture them as soon as the head is at the os uteri ; during their flow 
and after the head wdll move easily into its proper position." 

The procedure thus described is so simple, and would occupy so 
short a time, that there can be no objection to trying it. Should we 
fail in our endeavors, we shall not be in a worse position for effecting 
delivery by podalic version, which can be proceeded with without 
removing the hand from the vagina or in any way altering the position 
of the patient. 

The method of performing podalic version varies with the nature of 
each particular case. In describing the operation it has been usual to 
divide the cases into those in which the circumstances are favorable and 
the necessary manoeuvres easily accomplished, and those in w^hich there 
are likely to be considerable difficulties and increased risk to the mother. 
This division is eminently practicable, since nothing can be more varia- 
ble than the circumstances under which version may be required. Before 
describing the steps of the operation, it may be well to consider some 
general conditions applicable to all cases alike. 

In England the ordinary position on the left side is usually em- 
ployed. On the Continent and in America the patient is placed 
on her back, w^ith the legs supported by assistants, as in lithotomy. 
The former position is preferable, not only as a matter of custom and 
as involving much less fuss and exposure of the person, but because it 
admits of both the operator's hands being more easily used in concert. 
In certain difficult cases, w^hen the liquor amnii has escaped and the 
back of the child is turned toward the spine of the mother, the dorsal 
decubitus presents some advantages in enabling the hand to pass more 
readily over the body of the child ; but such cases are comparatively 
rare. The patient should be brought to the side of the bed, across 
which she sliould be laid, with the hips projecting over and parallel to 
the edge, the knees being flexed tow^ard the abdomen, and separated 



TURNING. 469 

from each other by a pillow or by an assistant. Assistants should also 
be placed so as to restrain the patient if necessary, and prevent her 
involuntarily starting from the operator, as this might not only embar- 
rass his movements, but be the cause of serious injury. 

The exliibition of ansesthetics is peculiarly advantageous. There is 
nothing which tends to facilitate the steps of the process so much as 
stillness on the part of the patient and the absence of strong uterine 
contraction. When the vagina is very irritable and the uterus firmly 
contracted round the body of the child, complete anaesthesia may enable 
us to effect version when without it we should certainly fail. 

The most favorable time for operating is when the os is fully dilated, 
before or immediately after the rupture of the membranes and the dis- 
charge of the liquor amnii. The advantage gained by operating before 
the waters have escaped cannot be overstated, since we can then make 
the child rotate with great facility in the fluid medium in which it 
floats. In the ordinary operation, in which the hand is passed into the 
uterus, it is essential to wait until the os is of sufficient size to admit of 
its being introduced with safety. This may generally be done when 
the OS is the size of a dollar, especially if it be soft and yielding. 

The practice followed with regard to the hand to be used in turning 
varies considerably. Some accoucheurs always employ the right hand, 
others the left, and some one or other according to the position of the 
child. In favor of the right hand it is said that most practitioners 
have more power with it, and are able to use it with greater gentleness 
and delicacy. In transverse presentations, if the abdomen of the child 
be placed anteriorly, the right hand is said to be the proper one to use, 
on account of the greater facility with which it can be passed over the 
front of the child ; and in difficult cases of this kind, when we are ope- 
rating with the patient on her back, it certainly can be employed with 
more precision than the left. In all ordinary cases, however, the left 
hand can be introduced much more easily in the axis of the passages, 
the back of the hand adapts itself readily to the curve of the sacrum, 
and even when the child's abdomen lies anteriorly it can be passed for- 
ward without difficulty so as to seize the feet. These advantages are 
sufficient to recommend its use, and very little practice is required to 
enable the practitioner to manipulate with it as freely as with the right. 
If, in addition, we remember that the right hand is required to operate 
on the foetus through the abdominal walls — and this is a point which 
should never be forgotten — we shall have abundant reasons for laying 
it down as a rule that the left hand slionld generally be employotl. 
Before passing the hand and arm they should be freely lubricated, with 
the exception of the palm, which is let! untouched to admit of a ti nn 
grasp being taken of the fa^tal limbs. It is also advisable to remove 
the coat and bare the arm as high as the elbow. 

As it shoidd be a cardinal rule to resort to the sinq>lest priKwlnre 
when })ractieable, it will be well to consider first the meiluxi by com- 
bined external and inte,rnal manipulation without passing the hand into 
the uterus, and subsequently that which involves the introduction oi^ 
the hand. 

Turning- by Combined External and Internal Manipulation. — To 



470 



OBSTETRIC OPERATIONS. 



Fig. 154. 



effect podalic version by the combiued method it is an essential prelim- 
inary to ascertain the situation of the foetus as accurately as possible. 
It will generally be easy in transverse presentation to make out the 
breech and head by palpation, while in head presentations the fonta- 
nelles will show to which side of the pelvis the lace is turned. The left 
hand is then to be passed carefully into the vagina^ in the axis of the 
canal, to a sufficient extent to admit of the fingers passing freely into 
the cervix. To effect this it is not ahvays necessary to insert the whole 
hand, three or four fingers being generally sufficient. 

If the head lie in the first (o.l.a.) or fourth (o.l.p.) position, push it 
upward and to the left, while the other hand, placed externally on the 
abdomen, depresses the breech toward the right (Fig. 154). By this 

means we act simultaneously on 
both extremities of the child's 
body, and easily alter its position. 
The breech is pushed down gently 
but firmly by gliding the hand 
over the abdominal wall. The 
head will now pass out of reach, 
and the shoulders will arrive at 
the OS and will lie on the tips of 
the fingers. This is similarly 
pushed upward in the same di- 
rection as the head (Fig. 155), the 
breech at the same time being 
still further depressed, until the 
knee comes within reach of the 
fingers, when (the membranes be- 
ing now ruptured, if still unbro- 
ken) it is seized and pulled down 
through the os (Fig. 156). Oc- 
casionally the foot comes imme- 
diately over the os, when it can 
be seized instead of the knee. 
Version may be facilitated by 
changing the position of the ex- 
ternal hand and pushing the head 
upward from the iliac fossa, in- 
stead of continuing the attempt 
to depress the breech i^Figs. 156 
and 157). These manipulations should always be carried on in the 
intervals, and desisted from when the pains come on ; and when the 
pains recur with great force and frequency the advantage of chloroform 
will be particularly apparent. In the second (o.d.a.) and third (o.d.p.) 
positions the steps of the operation should be reversed : the head is 
pushed upward and to the right, the breech downward and to the left. 
When the position cannot be made out with certainty, it is well to 
assume that it is the first (o.l.a.), since that is the one most frequently 
met with ; and even if it be not, no great inconvenience is likely to 
occur. If the os be not sufficiently open' to admit of delivery being 




First stage of Bipolar Version : Elevation of the 
Head and Depression of the Breech. (After 
Barnes.) 



TUB NINO. ill 

concluded, the lower extremity can be retained in its new position with 
one finger until dilatation is sufficiently advanced or until the uterus 

Fig. 155. 




Second Stage of Bipolar Version : Elevation of the Shoulders and Depression of the Breech. 

(After Barnes.) 

has permanently adapted itself to the altered position of the child ; either 
of which results will generally be effected in a short space of time. 

In transverse presentations the same means are to be adopted, the 
shoulder being pushed upward in the direction of the head, while the 

Fig. 156. 




Third Stage of Bipolar Version : Seizure of the Kuoo and Partial Klovatiou of the Head. 

(.After Uanios.) 

breech is depressed from without. This is tVoquently sutVicioni to briuiX 
the knees within reach, especially if the membranes are entire, but ver- 
sion is nuich facilitated by pressing- the head upward from without. 



472 



OBSTETRIC OPERATIOSS. 



alternately with depression of the breech. If the liquor amnii has 
escaped, and the uterus is firmly contracted round the body of the child, 
it will be found impossible to effect an alteration in its position without 
the introduction oi the hand, and the ordinaiy method of turning must 
be employed. The peculiar advantage of the combined process is, that 
it in no way interferes with the latter, for should it not succeed the hand 
can be passed on into the uterus without withdrawal from tlie vagina 

Fig. 157. 




Fourth Stage of Bipolar Version : Drawing Down of the Legs and Completion of Version. 

(After Barnes.) 



(provided the os be sufficiently dilated), and the feet or knees seized and 
brought down. 

Turning Avith the hand introduced into the uterus, provided the 
waters have not or have only recently escaj^ed and the os be sufficiently 
dilated, is an operation generally performed with ease. 

The first step, and one of the most important, is the introduction of 
the hand and arm. The fingers having been pressed together in the 
form of a cone, the thtimb lying between the rest of the fingers, the 
hand, thus reduced to the smallest possible dimensions, is slowly and 
carefully passed into the vagina, in the axis of the outlet, in an interval 
between the pains, and passed onward in the same cautious manner 
and with a semi-rotatory motion until it lies entirely within the vagina, 
the direction of introduction being gradually changed from the axis of 
the outlet to that of the brim. If uterine contractions come on, the 
hand should remain j^assive until they are over. It should ever be 
borne in mind as one of the fundamental rules in performing version 
that we should act only in the absence of pains, and then with the 



TURNING. 



Fig. 158. 



utmost gentleness, all force and violent pushing being avoided. The 
hand, still in the form of a cone, having arrived at the os, if this be 
sufficiently dilated, may be passed through at once. If the os be not 
quite open, but dilatable, the points of the fingers may })e gently insin- 
uated, and occasionally expanded, so as to press it open sufficiently to 
permit the rest of the hand to pass. While this is being done the uterus 
should be steadied by the other hand placed externally or by an assistant. 
If the presentation should not previously have been made out with accu- 
racy, we can now ascertain how to pass the hand onward so that its 
palmar surface may correspond with the abdomen of the child. 

Rupture of the Membranes. — The membranes should now be rup- 
tured, if possible, during the absence of pain, so as to prevent the 
waters being forced out. The hand and arm form a most efficient plug, 
and the liquor amnii cannot escape in any quantity. Some practition- 
ers recommend that before rupturing the membranes the hand should 
be passed onward between them and the uterine Avails until we reach 
the feet. By so doing we run the risk of separating the placenta; 
besides, we have to introduce the hand much farther than may be neces- 
sary, since the knees are often found lying quite close to the os. As 
soon as the membranes are perforated the hand can be passed on in 
search of the feet (Fig. 158). At this stage of the operation increased 
care is necessary to avoid anything 
like force; and should a pain 
come on, the hand must be kept 
perfectly flat and still, and rather 
pressed on the body of the child 
than on the uterus. If the pains 
be strong, much inconvenience 
may be felt from the compres- 
sion ; and were the onward move- 
ment continued, or the hand even 
kept bent in the conical form in 
which it was introduced, rupture 
of the uterine walls might easily 
be caused. This is not likely to 
occur in the class of cases now 
under consideration, for it is 
chiefly Avhen the waters have long 
escaped that tiie progress of the 
hand is a matter of difficulty. 
Valuable assistance may now be 
given by pressing the breech 
downward from without, so as 
to bring the knees or icet more 
easily within the reach of the in- 
ternal hand. Having arrived at 
tlie knees or feet, they may be 
seized between the fingers and 
<lrawn downward in the absence 
of a pain (Fig. 159). This wi 




Seizure of tbv 



Foot when the Uaml is Introduced 
into the rterus. 



cause the tanus to revolve on us axis. 



474 



OBSTETRIC OPERA TIOXS, 



the breech will descend^ and at the same time the ascent of the head 
may be assisted by the right hand from Avithout. It is a question with 

many accoucheurs which part of 
the inferior extremities should be 
seized and brought down. Some 
recommend us to seize both feet, 
others prefer one only, while some 
advise the seizure of one or both 
knees. In a simple case of turn- 
ing before the escape of the waters 
it does not matter much Avhich of 
these plans is followed, since ver- 
sion is accomplished with the 
greatest ease by any one of them. 
The seizure of the knee, however, 
instead of the feet, offers certain 
advantages which should not be 
overlooked. It is generally more 
accessible, affords a better hold 
(the fingers being inserted in the 
flexure of the ham), and, being 
nearer the spine, traction acts 
more directly on the body of the 
child. Any danger of mistaking 
the knee for the elbow may be 
obviated by remembering the sim- 
ple rule that the salient angle of 
the former, when the thigh is 
flexed, looks tow^ard the head of 
the child, of the latter toward its 
feet. Certain advantages may also 
be gained by bringing down one foot or knee only, instead of both. 
When one inferior extremity remains flexed on the body of the child, 
the part w^hich has to pass through the os is larger than when both legs 
are drawn down, and consequently the os is more perfectly dilated, and 
less difficulty is likely to be experienced in the delivery of the rest of 
the body, so that the risk to the child is materially diminished. 

Simpson, whose views have been adopted by Barnes and other 
Avriters, recommends the seizing, if possible, in arm presentations of the 
knee farthest from and opposite to the presenting arm, as by this means 
the body is turned round on its longitudinal axis, and the presenting 
arm and shoulder are more easily withdraw n from the os. Dr. Gala- 
bin has carefully investigated this point in a recent paper,^ and con- 
tends that there is a greater mechanical advantage in seizing the leg* 
which is nearest to, and on the same side as, the presenting arm ; and 
this, moreover, is generally more readily done. 

As soon as the head has reached the fundus and the lower extremity 
is brought through the os, the case is converted into a foot or knee pres- 
entation, and it comes to be a question whether delivery should now be 

^ Obst. Trans., for 1877, vol. xix. p. 239. 




Drawing Down of the Feet and Completion of 
Version. 



TURNING. 



4irj 



left to nature or terminated by art. This must depend to a certain 
extent on the case itself and on the cause which necessitated version, 
but generally it will be advisable to finish delivery without unnecessary 
delay. To accomplish this, downward traction is made during the 
pains and desisted from in the intervals (Fig. 160). As the umbilical 
cord appears, a loop should be 

drawn down ; and if the hands Fig. 160. 

be above the head they must be 
disengaged and brought over the 
face, in the same manner as in an 
ordinary footling presentation. 
The management of the head 
after it descends into the cavity 
of the pelvis must also be con- 
ducted as in labors of that descrip- 
tion. 

Turning in Placenta Prsevia. 
— In cases of placenta prsevia 
the OS will, as a rule, be more 
easily dilatable than in trans- 
verse presentations. Hicks' 
method offers the great advan- 
tage of enabling us to perform 
version much sooner than was 
formerly possible, since it only 
requires the introduction of one 
or two fingers into the os uteri. 
Should we not succeed by it, and 
the state of the patient indicates 
that delivery is necessary, we 
have at our command in the fluid 
dilators a means of artificially 
dilating the os uteri which can 
be employed with ease and safety. If we have to do with a case of 
entire placental presentation, the hand should be passed at that point 
where the placenta seems to be least attached. This will always be 
better than attempting to perforate its substance — a measure sometimes 
recommended, but more easily performed in theory than in practice. 
If the placenta only partially present, the hand should of course be 
inserted at its free border. It will frequently be advisable not to hasten 
delivery after the feet have been brought through the os, for they form 
of themselves a very efficient plug, and etleetually prevent further loss 
of blood; while if the patient be nnich exhausted she may have her 
strength recruited by stimulants, etc. before the completi(Mi of delivery. 

Turning- in Abdoniino-anterior Positions. — In abdiMuino-anterior 
})ositions, in which the waters have escaped, and in which, theivt'ore. 
some dilTicidty may be reasonably anticipated, the o[ieration is gener- 
ally more easily performed with the patiiMU on her bai'k : the right 
liand is then introduced into the uterus, and the lett employed exter- 
nally (Fig. 161). In this way the internal hand has to be passal a 




Showing the Completion of Version. 
(After Barnes.) 



476 



OBSTETRIC OPERATIOyS. 



shorter distance and in a less constrained position. The operator then 

sits in front of the patient, who is supported at the edge of the bed in 



Fig. ]61. 




Showing the Use of the Risht Hand in Ahdomino-anterior Position. 



the lithotomy position with the thighs ^separated, and the right hand is 
passed up behind the pubes and over the abdomen of the child. 

DiflBcult Cases of Arm Presentation. — The difficulties of turning 
culminate in those unfavorable cases of arm presentation in which the 
membranes have been long ruptured, the shoulder and arm pressed 
down into the pelvis, and the uterus contracted round the body of the 
child. The uterus being firmly and spasmodically contracted, the 
attempt to introduce the hand often only makes matters worse by indu- 
cing more frequent and stronger pains. Even if the hand and arm be 
successfully passed, much difiiculty is often experienced in causing the 
body of the child to rotate; for we have no longer the fluid medium 
present in which it floated and moved with ease, and the arm of the 
operator may be so cramped and pained by the pressure of the uterine 
walls as to be jendered almost powerless. The risk of laceration is 
also greatly increased, and the care necessary to avoid so serious an acci- 
dent adds much to the difficulty of the operation. 

Value of Anaesthesia in Relaxing the Uterus. — In these perplex- 
ing cases various expedients have been tried to cause relaxation of the 
spasmodically contracted uterine fibres, such as copious venesection in 
the erect attitude until fainting is induced, warm baths, tartar emetic, 
and similar depressing agents. Xone of these, however, are so useful 
as the free administration of chloroform, which has practically stiper- 
seded them all, and often answers most effectually when given to its 
full surgical extent. 

The hand must be introduced with the precautions already described. 



TURNING. 477 

If the arm be completely protruded into the vagina, we should pass the 
hand along it as a guide, and its palmar surface will at once indicate 
the position of the child^s abdomen. No advantage is gained by 
amputation, as is sometimes recommended. When the os is reached 
the real difficulties of the operation commence, and if the shoulder be 
firmly pressed down into the brim of the pelvis it may not be easy to 
insinuate the hand past it. It is allowable to repress the presenting 
part a little, but with extreme caution, for fear of injuring the con- 
tracted uterine parietes. Herman ^ has pointed out that in some cases 
the difficulty is increased by the shoulder of the prolapsed arm being 
caught beneath the contraction-ring (Bandl's), and he advises that it 
should be released by pressing it toward the centre of the cervical 
canal. It is better to insinuate the hand past the obstruction, which 
can generally be done by patient and cautious endeavors. Having 
succeeded in passing the shoidder, the hand is to be pressed forward 
in the intervals, being kept perfectly flat and still on the body of the 
foetus when the pains come on. It is much safer to press on it than 
on the uterine walls, which might readily be lacerated by the project- 
ing knuckles. When the hand has advanced sufficiently far, it will be 
better, for the reasons already mentioned, to seize and bring down one 
knee only. 

"When the Foot is brought Dcwn, but the Foetus ■will not 
Revolve. — Even when the foot has been seized and brouo^ht throu^rh 
the OS, it is by no means always easy to make the child revolve on its 
axis, as the shoulder is often so firmly fixed in the pelvic brim as not 
to rise toward the fundus. Some assistance may be derived from push- 
ing the head upward from without, which of course would raise the 
shoulder along with it. If this should fail, we may effi^ct our object 
by passing a noose of tape or wire ribbon round the limb, by which 
traction is made downward and backward ; at the same time the other 
hand is passed into the vagina to displace the shoulder and push it out 
of the brim. It is evident that this cannot be done as long as the limb 
is held by the left hand, as there is no room for both hands to pass into 
the vagina at the same time. By this manoeuvre version may be often 
completed when the foetus cannot be turned in the ordinary wav. 
Various instruments have been invented both for passing a fillet round 
the child's limb and for repressing the shoulder, but none of them 
can compete, either in facility of use or safety, with the hand of the 
accoucheur. 

"When Mutilation is Necessary. — Should all attempts at version 
fiiil, no resource is left but the mutilation of the child, either by evis- 
ceration or decapitation. Tliis extreme measure is, fortunately, sel- 
dom necessary, as with due care version may generallv be etVocted, 
even under the most unfavorable circumstances. 

^ " Note on One of the Causes of Difficulty in Turning," 06^/. 7Vcuiv>-., for lSSt.>, vol. 
xxviii. p. 150. 



478 OBSTEIEIC OPERATIONS. 



CHAPTER III. 

THE FOECEPS. 

Use of the Forceps in Modern Practice. — Of all obstetric opera- 
tions, the most important, because the most truly conservative, both to 
the mother and child, is the application of the forceps. In modern 
midwifery the use of the instrument is much extended, and it is now 
applied by some of our most experienced accoucheurs with a frequency 
Avhich older practitioners would have strongly reprobated. That the 
injudicious and unskilful use of the forceps is capable of doing much 
harm no one will for a moment deny. This, however, is not a reason 
for rejecting the recommendation of those who advise a more frequent 
resort to the operation, but rather for urging on the practitioner the 
necessity of carefully studying the manner of performing it, and of 
making himself familiar with the cases in which it is easy or the 
reverse. Nothing but practice — at first on the dummy, and afterward 
in actual cases — can impart the operative dexterity which it should be 
the aim of every obstetrician to acquire, and without which there can 
be no assurance of his doing his duty to his patient efficiently. 

Description. — The forceps may best be described as a pair of artificial 
hands by which the foetal head may be grasped and drawn through the 
maternal passages by a vis a fronte when the vis a tergo is deficient. 
This description w^ill impress on the mind the important action of the 
instrument as a tractor, to which all its powers are subservient. The 
forceps consists of two separate blades of a curved form adapted to fit 
the child's head ; a lock by which the blades are united after introduc- 
tion ; and handles which are grasped by the operator and by means of 
which traction is made. It would be a wearisome and unsatisfactory 
task to dwell on all the modifications of the instrument which have 
been made, which are so numerous as to make it almost appear as if 
no one could practice midwifery with the least pretension to eminence 
unless he has attached his name to a new variety of forceps. 

The Short Forceps. — The original instrument, invented by the 
Chamberlens, may be looked upon as the type of the short straight 
forcej^s, which has been more employed than any other, and which, 
perhaps, finds its best representative in the short forceps of Denman 
(Fig. 162). Indeed, the only essential difference between the two is 
the lock of the latter, originally invented by Smellie, which is so excel- 
lent that it has been adopted in all British forceps, and which for facility 
of juncture is much superior to either the French pivot or the German 
lock, while for firmness it is, for all practical purposes, as good as either. 
In this instrument the blades are 7, the handle 4f inches in length ; the 
extremities of the blades are exactly one inch apart, and the space 
between them at their widest part is 2J inches. The blades measure 



THE FORCEPS. 



479 



If inches at their greatest breadth, and spring with a regular sweep 
directly from the lock, tliere being no shank. The blades an^ formed 
of the best and most highly tempered steel to resist the strain to which 
they are occasionally subjected, and they are smooth and rounded on 
their inner surface to obviate the risk of injury to the scalp of the 
child. 

The special advantages claimed for this form of instrument is that, 
the two halves being precisely similar, no care or forethought is 

Fig. 162. 





Dcumaii's Short Forceps. 



required on the part of the practitioner as to which blade should l>e 
introdu(!ed uppermost — an advantage of no great value, since no one 
should undertake a case of forceps delivery who has not sufficient know- 
ledge of the operation and presence of mind enougli to obviate any risk 
from the introduction of the wrong blade first. Ou account of its 
.shortness and the want of the second or jielvic curve it is only adapted 
for cases in which the head is low down in the pelvis or actually rest- 
ing on the perineum. 

The Pelvic Curve. — The question of the second or pelvic curve is 
one on which there is nuich difference of opinion. The fortvps we are 
now considering (and the many modifications formed on the same \A:\\\) 
is constructed solely with reference to its grasp on the ehiUrs head, and 
without regard to the 'axes of the maternal passages. Consequently, 
were we to introduce it when the head was at the upper ]>art ot' ihe 
pelvis, we could not fail to expose the sot\ ]>arts to the risk ot' eoiuu-ion. 



480 



OBSTETRIC OPERATIOSS. 



Fig. 163. 



and (in consequence of the necessity of drawing more directly backward) 
unduly stretch and even lacerate the perineum. Hence it is now 
admitted by obstetricians, with few exceptions, that the second curve is 
essential before the complete descent of the head, although it is not ab- 
solutely so after this has taken place. The only circumstances under 
Avhich a straight blade can possess any superiority are in certain cases 
of occipito-posterior position in which it is found necessary to rotate the 
head round a large extent of the pelvis, when the circular sweep of a 
strongly curved instrument might prove injurious. Such cases, how- 
ever, are of rare occurrence, and need in no way influence the general 
employment of the pelvic curve. 

Zeig-ler's Forceps. — The short forceps usually employed in Scotland 
is the invention of the late Dr. Zeigler (Fig. 163), and is useful from 
the facility with which the blades may be introduced in accurate apposi- 
tion to each other — a point which in practice is of no little value. In 
general size and appearance it closely resembles Denman's forceps, but 
the fenestra of the lower blade is continued down to the handle. In 
introducing, the lower blade is slipped over the handle of the other 
blade, already in situ, and thus it is guided with great 
certainty into a proper position, locking itself as it 
passes on. This instrument has the disadvantage of 
not having the second curve, but the facility of intro- 
duction has rendered it a great favorite with many 
who have been in the habit of employing it. 

The Long" Forceps. — For cases in which the head 
is not on the perineum, or at least not quite low in 
the pelvis, a longer instrument is essential. To meet 
this indication Smellie invented the long forceps, 
wiiich, like the shorter instrument, has been very 
variously modified. The most perfect instrument of 
the kind employed in Great Britain is that known as 
Simpson's forceps (Fig. 164), which combines many 
excellent points selected from the forceps of various 
obstetricians, as well as some original additions, and 
which, as a whole, has never been surpassed until 
Tarnier's or its modification was invented. The 
curved portions of the blades are 6^ inches long, the 
fenestra measuring IJ in its widest part. The extremities of the blades 
are 1 inch asunder when the handles are closed, and three inches at 
their widest part. The object of this somewhat unusual width is to 
lessen the compressing power of the instrument, without in any way 
interfering with its action as a tractor. The pelvic curve is less than 
in most long forceps, so as to admit of the rotation of the head when 
necessary without the risk of injuring the maternal structure. Between 
the curve of the blade and the lock is a straight portion or shank 
measuring 2f inches, which before joining the handle is bent at right 
angles into a knee. This shank is a useful addition to all forceps, and 
is essential in the long forceps to ensure the junction of the blades 
beyond the parts of the mother, which might otherwise be caught in 
the lock and injured. The knees serve the purpose of preventing the 




Zeigler' s Forceps. 



THE FORCEPS. 



481 




e 



blades from slipping from each other after they have been united. 
They also admit of one finger being introduced above the lock and 
used as an aid in traction — a pro- 
vision which is made in some other Fi<^- 1^4. 
varieties of long forceps by a semi- 
circular bend in each shank. The 
handles, which in most British for- 
ceps are too small and smooth to 
afford a firm grasp, are serrated at 
the edge, and flattened from before 
backward, so as to fit the closed fist 
more accurately. At their extremi- 
ties, near the lock, there are a pair of 
projecting rests, over which the fore 
and middle fingers may be passed in 
traction, and which greatly increase 
our power over the instrument. Al- 
though this and other varieties of the 
long forceps are specially constructed 
for application when the head is high 
in the pelvis, it answers quite as well 
as the short forceps — indeed in most 
respects better — when the head has 
descended low down. It is a 
decided advantage for the practi- 
tioner to habituate himself to the 
use of one instrument, with the ap- 
plication and power of which he 
becomes thoroughly familiar. It is 
a mere waste of space and money Simpson's Forceps. 
for him to encumber himself with a 

number of instruments of various shapes and sizes, and he may be sure 
that a good pair of long forceps will be suitable for every emergency 
and in any position of the head. 

The chief argument against the use of such an instrument in simple 
cases is its great power. This, however, is entirely based on a miscon- 
ception. The existence of power does not involve its use, and the 
stronger instrument can be employed with quite as much delicacy and 
gentleness as the weaker. The remarks of Dr. Hodge ^ on this point 
are extremely apposite, and are Avell worthy of quotation. He Siiys : 
"Certainly no man ought to apply the forceps who has not sufiicieut 
discretion to use no more force than is absolutely requisite for safe 
delivery. If, therefore, there is more power at command, he is not 
obliged to use it; while, on the contrary, if nuich power be demanded, 
he can, within the bounds of j^rudence, exercise it by the k^jng forceps, 
but with the short forceps his etibrts might be unavailing. Moreover, 
in cases of difficulty, the short forceps being used, the practitioner 
would be forced to make great nniscular eiforts, while witli the long- 
forceps, owing to the great kn'cn-age, such etVort will be comparatively 

^ SiiMcm of ObsMrics, p. 'IA'2. 
31 



482 



OBSTETRIC OPERATIOXS. 



Fig. 165. 



trifling, and of course the whole force demanded can be much more 
delicately, and at the same time efficiently, applied, and with more safet}' 
to the tissues of the child and its parent." 

Continental Forceps. — The forceps usually employed on the Con- 
tinent and in America differs considerably, both in appearance and con- 
struction, from that in use in Great Britain. As a rule, it is a larger 
and more powerful instrument, joined by a pivot or button joint, and 
it always possesses the second or pelvic curve. Of late years Simp- 
son's forceps has been much employed in some parts of Germany. The 
chief objection to the continental instruments is their cumbrousness. This 
is chiefly in the handles, which in many of them are forged in a piece 
with the blades, the part introduced Avithin the maternal structures not 
being materially different from the corresponding part of the English 
instrument. 

Tarnier's Forceps. — The forceps invented by Professor Tarnier 
(Fig. 165) has recently attracted considerable attention. In this instru- 
ment traction is not made on the han- 
dles by which the blades are introduced, 
as in ordinary forceps, but on a supple- 
mentary handle {a) subsequently attached 
to the blades near the lower opening of 
their fenestrse (6). The object claimed 
for this arrangement is that less force is 
requii'ed in traction, which can always 
be made in the proper axis of the pelvis, 
that the blades are not likely to slip, and 
that rotation of the head is not interfered 
with. The handles of the forceps, more- 
over, guide the operator to the direction 
in which he ought to pull, since all that 
is required is to keep the traction-rods 
parallel to them. This instrument, how- 
ever, although theoretically perfect, is 
somewhat too complicated for general 
use. 

Simpson's Axis-traction Forceps. 
— Professor Simpson of Edinburgh has invented a modification of 
Tarnier's instrument, which he calls the '^ Axis-traction forceps " (Fig. 
166). The supplementary handles are fixed to the blades, and the 
w^hole mechanism is much simpler than in Tarnier's forceps. Dr. Simp- 
son reports very favorably of this forceps, and it is certainly well adapted 
for the object aimed at. For some- years I have used it extensively, 
and have every reason to be satisfied with it, especially in the high-for- 
ceps operation, in which it seems to me superior to any other instru- 
ment. 

Action of the Instrument. — The forceps is generally said to act in 
three different Avays : 
1st. As a tractor. 
2d. As a lever. 
3d. As a compressor. 




Tarnier's Forceps. 



THE FORCEPS. 



483 



Fig. 166. 




It is more especially as a tractor that the instrument is of value, and 
it is used with the greatest advantage when it is employed merely to 
supplement the action of the uterus, which is insufficient of itself to 
effect delivery, or when, from some com- 
plication, it is necessary to complete labor 
with greater rapidity than can be accom- 
plished by the unaided powers of nature. 
In most cases traction alone is sufficient ; 
but in order that it may act satisfac- 
torily, and that the instrument may not 
slip, a proper construction of the forceps 
and a sufficient curvature of the blades 
are essential. The want of these is the 
radical fault of many of the short, straight 
instruments in common use, which have 
a tendency to slip during our efforts at 
extraction. 

The forceps acts also as a lever, but 
this action has been greatly exaggerated. 
It is generally described as a lever of 
the first class, the power being at the 
handles, the fulcrum at the lock, and 
the weight at the extremities. There 
may possibly be some leverage power 
of this kind when the instrument is 
first introduced and the handles held 
so loosely that one blade is able to work 
on the other. But as ordinarily used the handles are held with a suf- 
ficiently firm grasp to prevent this movement, and then the two blades 
practically form a single instrument. 

Galabiu, who has studied this subject in detail, points out^ that '' 1. 
The lever is formed by both blades of the forceps and the fo?tal head 
united in one immovable mass. As soon as the blades begin to slip 
over the head the lever is decomposed, and the swaying movement 
ceases to have any mechanical advantage. 2. The power is ap})liod to 
the handles in a slanting direction. The resistance or weight does not 
act at a point either between the former and the fulcrum or beyond the 
fulcrum, but at a point in a plane nearly at right angles to the line join- 
ing these two points, and its direction is a line porpondicuhu' to that 
plane of the pelvis in which the greatest section of the liead is 
engaged ; that is to say, in the case of straight forco})s, nearly parallel 
to the handles. The lever formed does not, therefore, strictlv speak- 
ing, belong to any one of the three orders into which levers are ev>m- 
monly divided. 3. The fulcrum is fixed partly by friction, partly by 
the combination of traction with oscillatory movements — in other 
words, by the power being directed in great measure downward and 
only slightly to one side." 

lie further shows tlurt the pendulum motion of the foRvp is sujvr- 

^ Galabin, " Action of iNIidwiforv Forcoi^s as a Lever." Ohstdricul Journal, Novem- 
ber, 187(5. 



Simpson's Axis-Traction Forceps, 
c, h. Traction handle, c,/. Line of traction. 



484 OBSTETRIC OPERATIOyS. 

fluous in all ordinary forceps operations, in which traction alone is amply 
sufficient for delivery ; but that when the head is impacted and great 
force is required for its extraction a mechanical advantage may be gained 
from having recourse to an oscillatory movement, which should, how- 
ever, be very limited, and only continued if found to effect distinct 
advance of the head. 

Kegarding the compressive power of the instrument there has been 
much difference of opinion. There is no doubt that the forceps, 
especially some of the foreign instruments in Avhich the points nearly 
approach each other, is capable of exerting considerable compression on 
the head. It is, however, extremely problematical if this action be of 
real value. It is to be borne in mind that in cases of protracted labor 
the head has been already moulded and compressed, and the bones have 
been made to overlap each other to their utmost extent, by the sides of 
the pelvis. We can scarely, therefore, expect to diminish the head much 
more by the forceps without employing an amount of force that will 
seriously endanger the life of the child. It is in cases of disproportion 
between the head and the j^elvis, depending on slight antero-posterior 
contraction of the pelvic brim, that diminution of the child's head by 
compression would be most useful. Then, however, the pressure of the 
forceps is exerted on that portion of the head which lies in the most 
roomy diameter of the pelvis, where there is no want of space. If 
this pressure do not increase the opposite diameter, which is in apposi- 
tion to the narrower portion of the pelvis, it can at least do nothing 
toward lessening it, and diminution of any other part of the child's 
head is not required. 

Dynamical Action of the Forceps. — The mere introduction of the 
forceps sometimes excites increased uterine action, through the reflex 
irritation induced by the presence of a foreign body in the vagina. 
This has been called the dynamical action of the forceps, but it cannot 
be looked upon in any other light than that of an occasional accidental 
result. 

The circumstances indicating the use of the forceps have been sepa- 
rately considered elsewhere, and to recapitulate them here would only 
lead to needless repetition. I shall therefore now merely describe the 
mode of using the instrument. 

Before doing so it is well to repeat what has already been said as to 
the difference between what may be termed the high and low forceps 
operations. The application of the instrument when the head is low 
in the pelvis is extremely simple ; and when there is no disproportion 
between the head and the pelvis, and some slight traction is alone 
required to supplement deficient expulsive power, the operation in 
the hands of any ordinary well-instructed practitioner ought to be per- 
fectly safe both to the mother and child. It is very different when the 
head is arrested at the brim or high in the pelvis. Then the application 
of the forceps is an operation requiring much dexterity for its proper 
performance, and must never be undertaken without anxious considera- 
tion. It is because these two classes of operations have been confused 
that the use of the instrument is regarded by many with such unreason- 
able dread. 



THE FORCEPS. 48o 

Preliminary Considerations. — Before attempting to introduce the 
forceps there are several points to which attention should be directed: 

1st. The membranes must of course be ruptured. 

2dly. For the safe and easy application of the instrument it is also 
advisable that the os should be fully dilated and the cervix retracted 
over the head. Still, these two points cannot be regarded, as many 
have laid down, as being sine qua non. Indeed, we are often compelled 
to use the instrument when, although the os is fully dilated, the rim of 
the cervix can be felt at some point of the contour of the head, espe- 
cially in cases in which the anterior lip is jammed between the head 
and the pubes. Provided due care be taken to guard the cervical rim 
with the fingers of one hand as the instrument is slipped past it, there 
need be no fear of injury from this cause. If the os be not fully 
dilated, but is sufficiently open to admit of the passage of the forceps, 
the operation, under urgent circumstances, may be quite justifiable, Ijut 
it must necessarily be a somewhat anxious one. 

3dly. The position of the head should be accurately ascertained by 
means of the sutures and fontanelles. Unless this be done the opera- 
tion will always be haphazard and unsatisfactory, as the practitioner can 
never be in possession of accurate knowledge of the progress of the 
case. It may be that the occiput is directed backward ; and, although 
that does not contraindicate the application of the forceps, it involves 
special precautions being taken. 

4thly. The bladder and bowels should be emptied. 

Question of Adrainistering- Anaesthetics. — Before ])roceeding to 
operate the question of ansesthesia will arise. In any case likelv to 
be difficult it is of the greatest assistance to have the patient com- 
pletely under the influence of an anaesthetic to the surgical degree, so 
as to have her as still as possible ; but whenever this is deemed neces- 
sary another practitioner should undertake the responsibility of the 
administration. In simple cases I believe it is better to dispense with 
anaesthetics altogether, partly because they are apt to stop what pains 
there are — which is in itself a disadvantage — but chiefiy because under 
partial anaesthesia the patient loses her self-control, is restless, and twists 
herself into awkward positions which give rise to the utmost difficultv 
and inconvenience in the use of the instrument. INIoreover, if no ani>?s- 
thetic be given the patient can assist the operator by placing herself in 
the most convenient attitude. 

Description of the Operation. — In describing the method of aj>plv- 
ing the forceps I shall assume that we have to do with the simj)lor 
variety of the operation, when the head is low in the pelvis. Subse- 
quently I shall point out the peculiarities of the high operation. 

As to the position of the patient, I believe there can be no doubt ot' 
the superiority of that which is usually adopted in Great Britain. C^n 
the Continent and in America the lorceps is always emploved with the 
patient lying on her back — a position involving nuich ntHxlless exposuiv 
of the ])erson and requiring more assistance fi\>ni others. In certain 
cases of unusual ditficulty the position on the back is of unquestionable 
utility, but we may at least commence the operation in the usual wav, 
and subsequently turn the patient on her back it' desirable. 



486 OBSTETRIC OPEBATIOXS. 

Much of the facility with which the bLndes are introduced depends 
on the patieiit's being properly placed. Hence, although it gives rise 
to a little more trouble at first, I believe that it is always best to pay 
particular attention to this point, whether the high or low forceps ope- 
ration be about to be performed. The patient should be brought quite 
to the side of the bed, with her nates parallel to and projecting some- 
what over its edge. The body should lie almost directly across the bed, 
and nearly at right angles to die hips, with the knees raised toward the 
abdomen (Fig. 167). In this way there is no risk of the handle of the 

Fig. 167. 




Siiiil?^^^, ■»'•»• "■ I \ 



Position of Patient for Forceps Delivery, and Mode of Introducing Lower Blade 

upper blade, when depressed in introduction, coming in contact with the 
bed. 

The blades should be warmed in tepid water, lubricated with cold 
cream or carbolized vaseline, and placed ready to hand. 

These preliminaries having been attended to, we proceed to the intro- 
duction of the blades, sitting by the side of the bed opposite the nates 
of the patient. 

The important question now arises. In what direction are the blades 
to be passed ? The almost universal rule in our standard works is that 
they must be passed as nearly as possible over the child's ears, without 
any reference to the pelvic diameters. Hence, if the head have not made 
its turn, but is lying in one oblique diameter, the blades would require 
to be passed in the opposite oblique diameter ; in short, the posi- 
tion of the forceps as regards the pelvis must vary according to the 
position of the head. Some have even laid down the rule that the for- 
ceps is contraindicated unless an ear can be felt — a rule that would very 
seriously limit its a])plication, as in many cases in which it is urgently 
required it is a matter of great difficulty, and even impossibility, to feel 
the ear at all. It is admitted that in the high-forceps operation the 



THE FORCEPS. 487 

blades must be introduced in the transverse diameter of the pelvis, 
without relation to the position of the head. On the Continent it is 
generally recommended that this rule should be applied to all cases of 
forceps delivery alike, whether the head be high or low ; and I have 
now for many years adopted this plan and passed the blades in all 
cases, whatever be the position of the head, in the transverse diameter 
of the pelvis, without any attempt to pass them over the biparietal 
diameter of the child's head. Dr. Barnes points out with great force 
that, do what we will and attem])t as we may to pass the blades in rela- 
tion to the child's head, they find their way to the sides of the pelvis, 
and that the marks of the fenestrse on the head always show that it has 
been grasped by the brow and side of the occiput. Of the perfect cor- 
rectness of this observation I have no doubt ; hence it is a needless ele- 
ment of complexity to endeavor to vary the position of the blades in 
each case, and one which only confuses the inexperienced practitioner 
and renders more difficult an operation which should be simplified as 
much as possible. While, therefore, it is of importance that the precise 
position of the head should be ascertained in order that we may have 
an intelligent notion of its progress, I do not think that it is essential as 
a guide to the introduction of the forceps. 

Method of Introducing" the Lower Blade. — As a rule, the lower 
blade, lightly grasped between the tips of the index and middle fingers 
and thumb, should be introduced first. Poised in this way, we have 
perfect command over it and can appreciate in a moment any obstacle 
to its passage. Two or more fingers of the left hand are introduced 
into the vagina and by the side of the head as a guide. The greatest 
care must be taken, if the cervix be within reach, that they are passed 
within it, so as to avoid the possibility of injury. 

The handle of the instrument has to be elevated, and its point slid 
gently along the palmar surface of the guiding fingers until it touches 
the head (Fig. 167). At first the blade should be inserted in the axis 
of the outlet, but as it progresses the handle must be depressed and 
carried backward. As it is pushed onward it is made to progress by a 
slight side-to-side motion, and it is of the utmost importance to bear in 
mind that the greatest gentleness must always be used. If any obstruc- 
tion be felt we are bound to withdraw the instrument partially or entirely, 
and attempt to manoeuvre, not force, the point past it. As the bhide is 
guided on in this way, it is made to pass over the convexity of the head, 
the point being always kept slightly in contact with it, until it finally 
gains its proper position. A\'hen fully insei-ted the handle is drawn 
back toward the perineum, and given in chargt^ to an assistant. The 
insertion nuist be carried on (ndy in the intervals between the pains, 
and desisted from during their oecnnn^nce, otherwise there wcnild be 
a serious risk of injnring the soft parts of the mother. 

Introduction of the Upper Blade. — The second blade is passed 
directly opposite to the first, and is g(>nerally sonu^what more ditficult 
to introduce, in consequence of the space oceupieil by the latter. It 
is ])assed along two fingers directly oppt)site the tirst blade, and with ex- 
actly tlie same precautions as to din^'tion and introduction, except that 
at first its handle has to be depressLxl instead of elevated (Fig. 1G8). 



488 



OBSTETRIC OPERATIONS. 



The handle which was in charge of the assistant is now laid hold of 
by the operator, and the two handles are drawn together. If the blades 



Fig. 168. 




Introduction of the Upper Blade. 



have been properly introduced, there should be no difficulty in locking; 
but should we be unable to join them easily, we must withdraw one or 



Fig. 169. 




Forceps in Position : Traction in the Axis of the Brim Downward and Backward. 

other, either partially or entirely, and reintroduce it with the same pre- 



THE FORCEPS, 



489 



cautions as before. We must also assure ourselves that no hairs nor any 
of the maternal structures are caught in the lock. 

Method of Traction. — When once the blades are locked we may 
commence our eiForts at traction. To do this we lay hold of the 
handles with the right hand, using only sufficient compression to give 
a firm grasp of the head and to keep the blades from slipping. The 
left hand may be advantageously used in assisting and supporting the 
right during our efforts at extraction, and at a late stage of the opera- 
tion may be employed in relaxing the perineum when stretched by the 
head of the child. Traction must always be made in reference to the 
pelvic axes, being at first backward toward the perineum (Fig. 169), in 
the direction of the axis of the brim ; and as the head descends and the 
vertex protrudes through the vulva, it must be changed to that of the 
outlet (Fig. 170). If the axis-traction forceps is used, it is to be borne 

Fig. 170. 




Last stage of Extraction : The Handles of the Forceps are beiiiir sxraduallv turned upward 
toward the ^[other's Abdomen. 



in mind that traction is to be made by the traction handle i^nly, ihe 
handles of the instrument itself being left untouched after thev are 
locked and the traction-rods are united. By keeping these latter 
parallel to the handles of the forceps, traction can always be made in 
the ])roper direction. AVe nuist extract only during the pains, and if 
these should be absen^t we nuist imitate them by acting at intervals. 
This is a point which deserves special attention, tor there is no more 
common error than undue hurry in delivery. 

The only valid objection I know of against a more fivqiiont resort to 



490 OBSTETRIC OPERATIONS. 

the forceps in lingering labor is that the sudden emptying of the uterus 
in the absence of pains may predispose to hemorrhage ; and it cannot 
be denied that it is one of some weight. However, if due care be 
taken to operate slowly and to allow several minutes to elapse between 
each tractive effort, while at the same time uterine contrac^tions be 
stimulated by pressure and support, this need not be considered a 
contraindication. Besides direct traction we may impart to the instru- 
ment a gentle waving motion from handle to handle, which brings into 
operation its power as a lever ; but this must be done only to a very 
slight extent and must always be subservient to direct traction. 

Proceeding thus in a slow and cautious manner, carefully regulating 
the force employed according to the exigencies of the case, we shall per- 
ceive that the head begins to descend ; and its progress should be deter- 
mined from time to time by the fingers of the unemployed hand. 

When the head lies in the oblique diameter, as it descends in conse- 
quence of its perfect adaptation to the pelvic cavity, it will turn into the 
autero-po^terior diameter without any effort on the part of the operator, 
provided only that the traction be sufficiently slow and gradual. As 
the head is about to emerge it is necessary to raise the handles toward 
the mother's abdomen. More than usual care is required to prevent 
laceration of the perineum, which is always much stretched (Fig. 170). 
If, as often happens, the pains have now increased and the perineum be 
very thin and tense, it may even be desirable to remove the blades 
gently and leave the case to be terminated by the natural powers ; but 
if due precautions are used this need not be necessary. 

The peculiarities of forceps delivery in occipito-posterior positions 
have already been discussed (p. 326), and need not be repeated. 

Hig-h Forceps Operations. — When the high forceps operation has 
been decided on the passage of the blades will be found to be much 
more difficult, from the height of the presenting part, the distance 
which they must pass, and in some cases from the mobility of the head 
interfering with their accurate adaptation. The general principles of 
introduction and of traction are, however, identical. If tlie operation 
be attempted before the head has entered the pelvic brim, it must be 
fixed as much as possible by abdominal pressure. In guiding the 
blades to the head special care must be taken to avoid any injury of 
the soft parts, especially if the cervix be not completely out of reach. 
For this purpose it may even be advisable to introduce the entire left 
hand as a guide, so as to avoid any possibility of injuring the cervix 
from not passing the instrument under its edge. 

Peculiar Method of Introducing- the Blades. — Some authors 
advise that in such cases the blade should be introduced at first oppo- 
site the sacrum until the point approaches its promontory. It is then 
made to sweep round the pelvis under the protecting fingers till it 
reaches its proper position on the head. This plan is advocated by 
Ramsbotham, Hall Davis, and other eminent practical accoucheurs ; 
and it is certainly of service in some cases of difficulty, especially 
when, from any reason, it is not possible to draw the nates over the 
edge of the bed, when the necessary depression of the handle of the 
upper blade is difficult to effect. It involves, however, a somewhat 



THE FORCEPS. 491 

complicated manoeuvre, and it is seldom that the blades cannot be 
readily introduced in the usual way. 

In locking the slightest approach to rouglmess must be carefully 
avoided, for the extremities of the blades are now within the cavity of 
the uterus and serious injury might easily be inflicted. If difficulty be 
met with, rather than employ any force one of the blades should be with- 
drawn and reintroduced in a more favorable direction. If the blades 
have shanks of sufficient length, there should be no risk of including 
the soft parts of the mother in the lock, which in a badly-constructed 
instrument is an accident not unlikely to occur. 

Method of Traction. — After junction, traction must at first be alto- 
gether in the axis of the brim, and to effect this the handles must be 
pressed well backward toward the perineum. As the head descends it 
will probably take the usual turn of itself, without effort on the part 
of the operator, and the direction of the tractive force may be gradually 
altered to that of the axis of the outlet. If the pains be strong and 
regular, and there be no indications for immediate delivery, we may 
remove the forceps after the head has descended upon the perineum, and 
leave the conclusion of the case to nature. This course may be especi- 
ally advisable if the perineum and soft parts be unusually rigid, but 
generally it is better to terminate labor without removing the instru- 
ment. 

Possible Dang-er of Forceps Delivery. — Before concluding this 
subject reference may be made to the possible dangers of the operation. 
I would here again insist on the importance of distinguishing between 
the high and low forceps operations, which have been so unfortunately 
and unfairly confounded. Reasons have already been given for reject- 
ing the statistics of the risks attending forceps delivery in the latter 
class of cases (p. 353). A formidable catalogue of dangers, both to 
mother and child, might easily be gathered from our standard works 
on obstetrics. Among the former the principal are lacerations of the 
uterus, vagina, and perineum ; rupture of varicose veins, giving rise to 
thrombus ; pelvic abscess from contusion of the soft parts ; subsequent 
inflammation of the uterus or peritoneum; tearing asunder of the joints 
and symphyses; and even fracture of the pelvic bones. A careful 
analysis of these, such as has been so well made by Drs. Hicks and 
Phillips,^ proves beyond doubt that the application of the instrument is 
not so much concerned in their ])roduction as the protraction of the 
labor and the neglect of the practitioner in not interfering sufficiently 
soon to prevent tlie occurrence of the evil consequences afterward attrib- 
uted to the operation itself. Many of these will be found to rise from 
the prolonged pressure on the soft parts within tlie pelvis and the sub- 
se(|uent inflanunation or sloughing. To these causes mtiy be referred 
with proj)ri(4y most cases of vesico-vaginal fistula [\^. -14()\ peritonitis, 
and metritis following instrumental labor. 

Lacerations and similar accidents may, however, result from an incau- 
tious use of the instrument. Slight lacerations oi' the nuicous mem- 
brane of the vagina are probably far from inicoiuniou. Hut if these 
cases were closely examinetl it would be found that the thidt lav not in 

' Ob^t. Trii)t,<., 1S7-J. \o\. xiii. \\ ■^■\ 



492 OBSTETRIC OPERATIONS. 

the instrument, but in the hand that used it. Either the blades were 
introduced without due regard to the axes of the pelvis, or they were 
pushed forward with force and violence, or an instrument was employed 
unsuitable to the case (such as a short straight forceps when the head 
was high in the pelvis), or undue haste and force in delivery were used. 
It would be manifestly unfair to lay the blame of such results upon the 
forceps, which in the hands of a more judicious and experienced prac- 
titioner would have effected the desired object with perfect safety. The 
instrument is doubtless unsafe in the hands of any one who does not 
understand its use, just as the scalpel or amputating-knife would be in 
the hands of a rash and inexperienced surgeon. The lesson to be learnt 
seems to be clearly, not that the dangers should deter us from the use 
of the forceps, but that they should induce us to study more carefully 
the cases in which it is applicable and the method of using it with 
safety. 

Possible Risks to the Child. — The dangers to the child are, prin- 
cipally, lacerations of the integuments of the scalp and forehead ; con- 
tusion of the face ; partial but temporary paralysis of the face from 
pressure of a blade on the facial nerve ; depression or fracture of the 
cranial bones ; injury to the brain from undue pressure of the blades. 
These evils are of rare occurrence, and when they do happen generally 
result from improper management of the operation — such as undue com- 
pression, the use of improper instruments, or excessive and ill-directed 
efforts at traction — and cannot therefore be considered as in any way 
contraindicating the use of the instrument. Many of the more common 
results, such as slight abrasions of the scalp or paralysis of the face, are 
transitory in their nature and of no real consequence. 

[The Forceps in America. — Although the obstetrical forceps was 
first used in England, other countries in the march of improvement 
have made great changes, not only in the original forms, but in the man- 
ner of use, and various shapes, as well as different positions of the 
woman in application, have become in a measure national. With the 
exception of having adopted almost exclusively the French and German 
dorsal decubitus in making use of the instrument, we have become in a 
measure eclectic in the selection of the latter ; medical schools, accouch- 
eurs, and local obstetrical societies influencing students and the junior 
members of the profession to adopt the French, German, English, or 
American style, as the case may be, the forceps themselves bearing the 
names of the several inventors or compilers ; for some are a true com- 
pilation — the blade from one contriver ; fenestral openings, another ; 
pelvic curve, a third ; width, a fourth : shanks, a fifth ; method of lock- 
ing, a sixth ; etc. etc. For this reason the late Prof. Hodge named his 
forceps the eclectic, although in some respects entirely original, particu- 
larly in the long superimposed shanks — a great improvement for ope- 
rating at the superior strait and avoiding the painful stretching of the 
posterior commissure of the vulva. Dr. Hodge expended a great deal 
of thought and money in perfecting his forceps, and the various steps 
in the process were marked by a new form, until, from a heavy, clumsy 
instrument, he gradually evolved what was at one time regarded as a 
wonderful improvement upon the forceps of France and England. 



THE FORCEPS. 493 

A contemporary of Prof. Hodge, the late Prof. David D. Davis of 
London, was equally anxious to perfect the instrument, and turned liis 
attention especially to making the blades light, open, and to fit the sides 
of the foetal head so as to enable traction to be made without much pres- 
sure or leaving any mark on the child's scalp. There is a principle of 
mechanics involved in his instrument which he studied to perfect by 
moulding the blades so as to obtain considerable coaptating surface, and 
thus by increase of friction to avoid undue and dangerous pressure. 
The Davis blade soon began to effect changes in the form of American 
forceps, and by the addition of long handles and some alterations of 
shape, weight, and curve became a leading feature in those bearing the 
names of William Harris, Prof. Wallace of the Jefferson Medical Col- 
lege, Dr. Bethel, and Albert H. Smith, all of this city. The short Davis 
instrument was a great favorite with the late Prof. Meigs and Dr. Wil- 
liam Harris, both largely engaged in obstetrical practice as ^vell as 
teaching ; and many a delicate woman with wasting forces was aided in 
her delivery at their hands, and was surprised to find no mark on the 
baby's head, and that her own sufferings could be so gently and safely 
relieved. 

Although such was the estimation of the Davis blade, and still is in 
many parts of our country, it does not appear to have retained its popu- 
larity or been adopted, as its mechanical perfection would lead one who 
appreciates it to suppose it would have been. In Great Britain the 
favorite forms now in use are but a very slight improvement upon the 
forceps of a hundred years ago except in finish and material, the open 
fenestrse and bevelled blades of Davis being declined in favor of the 
looped fenestrse and flat-edged blades in use when he made his experi- 
ments and changes. This appears to have grown out of a practice which 
has been largely adopted in Germany, Great Britain, and many parts of 
the United States in applying the forceps to the foetal head, the blades 
being introduced at the sides of the pelvis, without much reference to the 
position which the head occupies. As compression is objected to, the 
blades are made long and widely separated (SJ to 3J inches), and the 
handles short, so as not to allow of much leverage. As the blades do not 
fit the head, the mechanism of labor as taught by Hodge has been much 
simplified, as it is not necessary to learn all the oblique fittings of the 
fenestrse over the parietal protuberances or ears. Dr. ]Meigs used to tell 
the students that the forceps was the ^^ehlhVs iusirumcnt,'' and should 
be used as a tractor ; and it was as a well-api)lied mechanical tractor 
that he advocated the use of the Davis blades against those of Siebold, 
Levrct, Baudelocque, and Halghton, employed generally in our country 
forty years ago. His language is not very complimentary to what he 
denominates by distinction " the )nothcr\^ iustrumoif,'' the form being 
better adapted for saving the woman than the ftvtus.^ 

At the present day we have two general orders of forceps in use in 
the United States, under each of which may be placed a vast number 
of special varieties which are simply changes upon one or the other gen- 
eral type according to 'the fancy of the inventor. At the head oi' one 
type may be placed the long forceps of Prof Ilodge, designed to l>o 

[^ Obsktrici^, p. 540.] 



494 OBSTETRIC OPERATIOXS. 

adapted to the sides of the child's head in all possible cases ; and of the 
other, those of Prof. Simpson of Edinburgh or their modification by 
Profs. Elliot and Bedford of Xew York, intended to be used as trac- 
tors, and applied in reference to the sides of the mother's pelvis, rather 
than to those of the infant's head. 

Taking the long forceps of Levret and Baudelocque as improved and 
modified by Hodge, ^vith the blades of Prof. Davis as a substitute, and 
handles of less curv^e than those of Hodge, and ^\e have the long for- 
ceps of Prof. Ellerslie AYallace, late of Jefferson Medical College, the 
most frequent choice of those who purchase forceps of the manufacturers 
in Philadelphia. Xext in order are the instruments of Hodge, Davis, 
and Simpson, Elliot, Bedford, and a few others — in all about a dozen 
forms that vary in popularity. The improvement of the late Prof. 
Elliot upon the instrument of Simpson consists in narrowing and length- 
ening the shanks, widening somewhat the fenestrse, elongating the blades, 
giving greater security against slipping in the handles, and gauging the 
distance between the blades by a milled-head screw-stop in the end of 
the handles : the shanks and blades are an exact counterpart of the 
Miller forceps of England, which appeared about the same time (1858). 

The Hodge forceps was based in its contrivance upon the following 
points : 1. The instrument should be shaped to the contour of the foetal 
head, and have sufficient play to allow of compression where the pelvis 
is too narrow for the head to pass in its normal condition. 2. The 
blades should be so arranged in reference to the shanks and handles as 
to enable them to seize the head of the foetus in its biparietal diameter 
at the superior strait, and be drawn upon in the direction of the curve 
of the pelvic canal until the delivery is complete. 3. The long forceps 
ought to be competent to act either at the superior strait of the pelvis, 
in its cavity, or at its outlet, so as to avoid a multiplicity of instruments 
and their attendant expense. And, 4. The instrument should not cut 
the scalp of the child if properly adjusted, or injure the soft parts of 
the mother. 

It w^ould be folly to claim that all this could or has been accom- 
plished, as there must necessarily be exceptional cases in all the points 
given ; hence the contrivance of the forceps of Tarnier and Cleemann 
for certain presentations above the superior strait, and the long and short 
convertible instruments of a few inventors. There are many cases of 
labor in the higher walks of life w^here, although there is no obstruc- 
tion, still the women require manual or instrumental assistance, as they 
cannot deliver themselves for want of sufficient contractile muscidar 
force. Such women require that the forceps used should be easily 
introduced — should act simply as tractors, control the movement of the 
foetal head by being well fitted to its shape, and leave no effect upon 
the scalp or vulva. Although these requisites may be filled by the 
Hodge instrument, it is this class of cases that has demanded a lighter 
and more roomy pair of forceps, such as that devised by Davis. 

As the teaching of the Jefferson ]\Iedical College under Dr. Meigs 
favored, as we have stated, the forceps of Davis, so his successor, Prof. 
Wallace, in carrying out in a measure the same views, combined the 
blades of the Davis pattern with the long handles of Hodge in con- 



THE FORCEPS. 



49o 



triving what is known os the ^^ Wallace /orce/^s-/' now so much in use 
by the large number of graduates of this schooh As compared with 
the Hodge instrument^ it is 1 inch shorter (15 inches against 16j; the 
blades are of the same length (6 inches) ; the fenestr^e are more open ; 
the shanks are only half the lengthy giving much greater compressing 



Fig. 171. 



Fig. 172. 



Fig. 173 




Hodge Forceps. 



Wallace Forceps. 



Davis Forceps. 



power ; and the handles are of the same measurement from pivot to 
hooks. Botli have the Siebold lock, over which we believe the broad- 
top})ed button and notch to possess some advantages ; and the Wallace 
is somewhat heavier than the Hodge, which should weigh 17 ounces. 

The short Davis instrument made for Prof jNIeigs under direction o^ 
the inventor weighed lOJ ounces and measured VI inches in lenoth ; 



wid 



c : 



►hides 



separated *l'i uiclies 



fenestra^, 5 inches long, 2 mcnes 

handles, 4] inches to lock, which was of the Smellie or Knglish \\\x- 
tern. A recently-piu'chased pair in possession of the txlitor is lo^ 
inches long, with 5-inch handles, a button lock, 2-inch close-set shanks" 
and ()X-inch blades. \ believe iW changes are decided improvements, 
especially the lock and elongated handles. It has answered admirablv 
in adynamic cases requiring only a few pounds (}( tractile a>sisiance. 



496 



OBSTETRIC OPERATIONS. 



Fig. 174. 



Fig. 175. 



The Davis blades have been added to long handles, and the whole 
made of steel and marvellously light, at the special request of a few 
accoucheurs, who wished them to aid in some cases of arrest at the 
perineum. 

The late Prof. George T. Elliot of New York, who received much 
of his practical obstetrical training in the Dublin Lying-in Hospital, 
imbibed the teachings of the English school, and became impressed with 
the value of the system as taught by Simpson, upon the principle of 
whose forceps, modelled somewhat after that of the late Prof. Gunning 
S. Bedford of New York, he in 1858 presented to the medical profes- 
sion the instrument that bears his name. The forceps of Prof. Bedford 
has a traction-ring on each side where the Elliot has a cornu, has a but- 
ton joint, instead of a Smellie, has no screw top, and has diverging 
instead of superimposed shanks. These points have generally been con- 
sidered as improvements, and hence the Elliot has taken precedence in 
large measure over the Bedford instrument in New York, the two being 
the leading forceps in demand. The instrument of White of Buffalo is 
perhaps next, and then Hodge's. But few of Prof. Wallace's forceps, 

long the leading instrument in 

Philadelphia sales, are ordered. 

The White is a long forceps, a 

compound of the Elliot blade, 

long superimposed shanks of 

Hodge, Siebold lock, and short 

corrugated steel handles bowed 

out like dental forceps and end- 
jj ing in thin blunt hooks. 

The Sawyer and Simpson 

short forceps are said to be 

about equally in demand in 

New York. The former is 

almost unknown in Philadel- 
phia, and but comparatively few 

of the Simpson are asked for, al- 
though the system of their appli- 
cation has several advocates in 

this city. 

The Sawyer Forceps. — This 

is the lightest of all the varieties 

of the short forceps, weighing 

but 5 ounces, and measuring 9f 

inches in length; the handle 

being 3 inches, shank IJ, and 

chord of blade-curve b\. The 

blades are IJ inches wide, with oval fenestras ^ inch 

Avide, and separated 2| inches at their widest part and 
Elliot Forceps. f i^^ch at the tips. This instrument was invented eight 

years ago by Prof. Edw. Warren SaAvyer of Rush Med- 
ical College, Chicago, and has been highly commended by Prof. Byford 
and others. The forceps has the blades of Davis, superimposed shanks 




Sawyer Forceps. 



THE FORCEPS. 497 

of Hodge, and lock of Smellie^ v/ith hardrubber plates moulded hot 
upon the handles. The several parts have been somewhat modified, the 
object being to secure a tractor for cases of deficient expulsive force where 
the foetal head is low in the pelvis. 

Professor Sawyer says: 'Mn the labors to which my forceps is appli- 
cable it is not necessary for the operator's body to be in line with the 
pelvic axis. My mode of procedure is the following : The w^oman is 
placed upon- her back and drawn to the edge of the bed ; the outside leg 
is now flexed ; beneath this flexed extremity and the bed-covering 1 
apply the forceps — often using but one hand in the operation. When , 
the instrument is locked, I grasp the handle in such a manner that the ' 
palm of the hand looks upward ; one hook then rests naturally upon 
the extensor surface of the first phalanx of the index finger, while the 
other hook rests upon a corresponding part of the thumb. When thus 
adjusted, T lift the head from the pelvic outlet, at the same time invok- 
ing the pendulum movement if desired. At this moment the advan- 
tage of the hooked handle is very apparent to the operator." .... 
^'AU practitioners must have often felt, during the last moments of labor, 
when the uterus and the mother seemed fatigued, the need of a little help 
to the expulsive powers. The ordinary instruments are too formidable 
to be used at the last moment, and it is then that this little forceps is 
useful. '^ 

I have given the names and characters of the various forceps most in 
use in New York and Philadelphia, and by the large number of gradu- 
ates of their respective schools, as shown by their preferences in select- 
ing instruments of the leading makers of the two cities. The mechan- 
ism of instrumental delivery is much simplified by applying the forceps 
to whatever parts of the foetal head may be opposite the sides of the 
pelvis, but it is very questionable whether it is the scientific method 
or the safer for the child. With one blade over the side of the occiput, 
and the other over that of the forehead — which is the manner of seizure 
in oblique positions of the vertex — we certainly have not a very secure 
liold and run some risk of injury to the foetus. The advocates of this 
system claim that they use no compression, only a simple traction ; 
which may be true in one sense, but amounts to the same in eflect, else 
how could Dr. Elliot, by traction with great force, straighten out one 
of the blades of his Simpson forceps, as related in the Xew York Jouru. 
of Medicine for September, 1858, p. 161, in the paper which he pre- 
sented describing his new forceps and a number of cases in which he 
had tested them? It makes but little difference whether mc compress 
the head before we begin to pull, or pull so as to wedge the head 
between the l)lades, and thus compress it, except as to the difference ot* 
fit in the two instances ; the adjusted and even pressure being the less 
likely to injure the foetus. I Iiave always believed that the forceps 
should fit the head, and that the student' should be taught how to 
accom})lish it correctly in the various positions of the iVvtus. It' the 
student has a mechanical turn o{' mind, a delicate sense o^ touch, and a 
clear head, he will soon learn ; if he is not a nieclinnit', he will be tbnwl 
to adopt a more simple method of delivery. In a large ciiy there are 
but few first-class obstetric^d manipulators as a general rule, and they 



498 



OBSTETBIC OPERA TIOXS. 



are usually well knowu as such, for the reason that but few have all the 
requisites to enable them to achieve notoriety ; and vet there are hun- 
dreds who can deliver a woman with forceps moderately well. To one 
the mechanism of Hodge is a simple matter and soon mastered ; to 
another it is a useless complication, and he prefers the more simple svs- 
tem. Hence the great diiferences between oljstetricians as to the best 
instrument and the best method of application. Some of the vast arrav 
of patterns have decided merit and display much mechanical skill, while 

Fig. 176. 




Application of the Forceps at the Inl'erior Strait. 



Others serve only to amuse the educated examiner. One obstetrician, 
after the manner of Elliot, uses a variety of forceps one after another in 
the same case, and pulls with great force, while another confines his 
work almost to one instrument, adjusts it easily, pulls moderately, and 
seldom fails. There are no dotibt excej^tions, but certainly the most 
delicate manipulators we have seen believed in and practised the teach- 
inps of Hodoe and Melons. There mav be cases where it mio^ht be well 
to practise the method of Simpson, as is done occasionally by some of 
our leading practitioners, but we cannot see why his plan of delivery 
should be exclusivelv used on anv mode of scientific reasonino-. 



THE FORCEPS. 



499 



I present a series of plates in illustration of the American method of 
delivery with the forceps, the position, as will be seen, being that of 
France and Germany — on the back. When it is decided to use the for- 
ceps, in almost all cases in the United States the patient is brought to 
the edge of the bed on her back, with her nates close to the edge, her 
feet on two chairs, and her knees widely separated, as in the plate above. 
The patient is covered with a sheet, or heavier covering if in winter, 
and there is no necessity of exposure, as the whole manipulation may 
be done by the sense of touch. The position is by far the most con- 
venient for the obstetrician, and enables him much more easily to keep in 

Fig. 177. 




Application of the Foroops with the Head at the Superior Strait, the loi't blade hold in 
place by an assistant. 



his mind all the anatomical relations of the fivtus and pol\ is ilian whon 
in the English decubitus. Wo study the anatomy witli the subjoct on 
the back, and the mechanism of labor in front of the pelvis or manikin ; 



500 



OBSTETRIC OPERATIONS. 



then why complicate matters by a change of position, which, to say the 
least, is a very awkward one, particularly in introducing the long for- 
ceps, setting it according to the instructions of Hodge, and carrying it 
forward between the thighs as the head emerges ? I have used the short 
forceps in an exhausted case with the woman on her side, but found it 
much less convenient for the various movements, although I soon deliv- 
ered the foetus. As to the question of exposure, there is less in appear- 
ance than, in fact, in the English position in many cases. If the patient 
and nurse are fastidious and careful during the use of the forceps, the 
accoucheur can manage without his eyes in a large proportion of cases ; 
but the fault of exposure lies moj-e frequently in the temporary reckless 
indifference begotten of pain and suffering in the woman, than in any 
act of the accoucheur if inclined to spare the feelings of his patient as 
much as possible. 

The long forceps, with its pelvic curve, was specially designed for 
use at the superior strait of the pelvis, the curve of the blades, as in 
the Davis instrument modified by Wallace, being intended to corre- 

FiG. 178. 




Direction of the Forceps as the Head is being Delivered. 



spond with the direction of the occipito-mental diameter of the foetal 
head. The long superimposed shanks of several varieties of the long 
forceps will here be found valuable, as the lock is not introduced or 
the posterior commissure of the vulva widely stretched. If the head 



THE FORCEPS. 501 

is entirely above the strait, the line of the blades must be changed 
correspondingly, in order to apply them properly and keep the line 
of traction within the coccyx ; and even then, to draw in the proper 
direction, the left hand must act at first in a backward direction fnjm 
the lock, while the right brings the handles downward, forward, and 
then upward ; both hands describing a curve, but that of the right 
being much the greater. The peculiar forceps of Tarnier or of Clee- 
mann, being designed to meet this form of exigency, may be brought 
into requisition. These both have the blades of Davis. 

In latter years it has become much more common than formerly to 
introduce the forceps into the uterus before it is fully dilated, in conse- 
quence of the success claimed for the plan as carried out in the Dublin 
Lying-in Hospital. As this should never be done where the os is not 
readily dilatable, and requires much skill in execution, it is not safe to 
recommend its general adoption in cases of delay in private practice. 

The forceps should not be introduced with any force, but the left 
blade should be slid in gently and with a spiral motion, and then the 
right, care being taken that they should also lock without force, w^hich 
they will do if properly adjusted. Traction is to be exerted slowly 
and during a pain, the whole movement being made to correspond 
with the natural as closely as possible. 

As the foetal head comes under the arch of the pubes the handles of 
the forceps must rise more and more from the bed, until at last they are 
over the abdomen as the head emerges from the perineum. This last 
movement of instrumental delivery should be a very slow one, for fear 
of rupture. It has been proposed to remove the blades before delivery 
is complete ; but there is no occasion for this if the forceps is applied to 
the sides of the head over the parietal protuberances, as, where these 
protrude and the blades are flat and thin, there is very little additional 
space required. With such instruments as the old Levret, Bandelocque, 
and Rohrer forceps, with looped or kite-shaped fenestnie and thick edges, 
this was a much more imperative direction than with the better instru- 
ments of the present day. With a Sawyer forceps the perineum ought 
to be safer and under better control than without. When the perineum 
is thought to be in danger, the process of distension should be retarded 
through two or three pains, or even more if required, instead of draw- 
ing the head through at once. 

After the head is delivered, if the cord is not around the neck and 
therefore in danger from pressure, the body shoukl be allowed to remain 
until the uterus has well contracted upon it, for fear of hemorrhage after 
delivery, from uterine inertia. — Ed.] 



502 



OBSTETRIC OPERA TIOXS. 



CHAPTER lY 



THE VECTIS.— THE FILLET. 



Fig. 179. 



The Vectis. — In coDoection with the subject of iDstriimental deliv- 
ery it is essential to say something of the use of the vectis^ on account 
of the value which was formerly ascribed to it, which was at one time 
so great in England that it became the favorite instrument in the 
metropolis; Denman saying of it that even those who employed the for- 
ceps were " very willing to admit the equal, if not superior, utility and 
convenience of the vectis." Even at the present day there are practi- 
tioners of no small experience who believe it to be of occasional great 
utility, and use it in preference to the forceps in cases in which slight 
assistance only is required. In spite, however, of occasional attempts to 
recommend its use, the instrument has fallen into disfavor, and mav be 
said to be practically obsolete. 

Nature of the Instrument. — The vectis in its most approved form 
consists of a single blade, not unlike that of a short straight 
forceps, attached to a wpoden handle. A variety of modifica- 
tions exists in its shape and size. The handle has been occa- 
sionally manufactured, for the convenience of carriage, with a 
hinge close to the commencement of the blade (Fig. 179) or 
with a screw at the point where the handle and blade join. 
The power of the instrument and the facility of introduction 
depend very much on the amount of curvature of the blade. 
If this be decided, a firmer hold of the head is taken and 
greater tractive force is obtained, but the difficulty of intro- 
duction is increased. 

When employed in the former way the fulcrum is intended 
to be the hand of the operator ; but the risk of using the 
maternal structures as a point cVappid, and the inevitable dan- 
ger of contusion and laceration which must follow, constitute 
one of the chief objections to the operation. Its value as a 
tractor must always be limited and quite inferior to that of the 
forceps, while it is as difficult to introduce and manipulate. 
Cases in -which it is Applicable. — The vectis has been 
recommended in cases in which the low forceps operation is 
suitable, provided the pains have not entirely ceased. There is no 
doubt that it may be quite capable of overcoming a slight impediment 
to the passage of the head. It is applied over various parts of the 
head, most commonly over the occiput, in the same manner, and with 
the same precautions, as one blade of the forceps. Dr. Ramsbotham 
says : " We shall find it necessary to apply it to different parts of the 
cranium, and perhaps the face also, successively, in order to relieve the 
head from its fixed condition and favor its descent." Such an opera- 



THE VECTIS.—TITE FILLET, 



Fig. 180. 



tion obviously requires quite as niueh dexterity as the application of 
the forceps, while, if we bear in mind its comparatively slight power 
and the risk of injury to the maternal structures, we must admit that 
the disuse of the instrument in modern practice is amply justified. 

The vectis may, however, find a useful application w^hen employed 
to rectify malpositions, especially in certain occipito-posterior presenta- 
tions. This action of the instrument has already been considered 
(p. 325), and under such circumstances it may prove of service where 
the forceps is inapplicable. When so employed it is passed carefully 
over the occiput, and while the maternal structures are guarded from 
injury downward traction is made during the continuance of a pain. 
So used, its application is perfectly simple and free from danger, and 
for this purpose it may be retained as part of the obstetric armamen- 
tarium. 

The Fillet is the oldest of obstetric instruments, having been fre- 
quently employed before the invention of the forceps, and even in 
the time of Smellie it was much used in London. It has since com- 
pletely fallen out of favor as a scientific instrument, although its use is 
every now and again advocated, and it is certainly a favorite instru- 
ment with some practitioners. This is to be explained by the apparent 
simplicity of the operation, and the fact that it can generally be performed 
without the knowledge of the patient. The 
latter, however, is one strong reason why it 
should not be used. 

Nature of the Instrument. — The fillet 
consists, in its most improved form (that 
which is recommended by Dr. Eardley Wil- 
mot^) (Fig. 180), of a slip of whalebone 
fixed into a handle composed of two sepa- 
rate halves, which join into one. The whale- 
bone loop is slipped over either the occiput 
or face, and traction used at the handle. 

When applied over the fixce after the head 
has rotated, it would probably do no harm, 
but if it were so placed when the head was 
liigh in the pelvis, traction would necessarily 
produce extension of the chin before the 
])roper time, and would thus interfere with 
the natural median ism of delivery. If 
placed over the occiput, it is impossible to 
make traction in the direction of the pelvic 
axes, as the instrument w'lW then infallibly 
slip. If traction be made in any other di- 
recition, \\\o\\^ nuist be a risk of injuring the 
maternal structures or of changing the }H)si- 

tion of the head. Hence there is every reason for discarding the fillet 
as a tractor or as a sijbstitute for the forceps, even in the simplest 
cases. 

It is quite possible that it may find a useful npi^lication in certain 
* Obst. Tram., 1874, vol. xv. \\ ITJ. 




ft) 






Wihnol's Fillot. 



504 OBSTETRIC OPERATIONS. 

cases in which the vectis may also be used — viz. as a rectifier of mal- 
position, and from the comparative facility of its introduction it would 
probably be the preferable instrument of the two. 



CHAPTEE y. 

OPEEATIONS INVOLVING DESTKUCTION OF THE FCETUS. 

Operations involving the destruction and mutilation of the 
child were among the first j^ractised in midwifery. Craniotomy was 
evidently known in the time of Hippocrates, as he mentions a mode of 
extracting the head by means of hooks. Celsus describes a similar ope- 
ration, and was acquainted with the manner of extracting the foetus in 
transverse presentations by decapitation. Similar procedures were also 
practised and described by Aetius and others among the ancient writers. 
The physicians of the Arabian school not only emplo}'ed perforators for 
opening the head, but were acquainted with instruments for compressing 
and extracting it. 

Relig-ious Objections to Craniotomy. — Until the end of the seven- 
teenth century this class of operation was not considered justifiable in 
the case of living children : it then came to be discussed whether the 
life of the child might not be sacrificed to save that of the mother. It 
was authoritatively ruled by the Theological Faculty of Paris that the 
destruction of the child in any case was mortal sin : '■^ Si Ton ne pent 
tirer I'enfant sans le tuer, on ne pent sans pech6 mortel le tirer." This 
dictum of the Eoman Church had great influence on continental mid- 
wifery, more especially in France, where up to a recent date the leading 
obstetricians considered craniotomy to be only justifiable when the death 
of the foetus had been positively ascertained. Even at the present day 
there are not wanting practitioners who, in their praiseworthy objections 
to the destruction of a living child, counsel delay until the child has 
died — a practice thoroughly illogical, and only sparing the operator's 
feelings at the cost of greatly increased risk to the mother. In England 
the safety of the child has always been considered subservient to that 
of the mother ; and it has been admitted that in every case in which 
the extraction of a living foetus by any of the ordinary means is impos- 
sible its mutilation is perfectly justifiable. 

Formerly Performed with Unjustifiable Frequency. — It must 
be admitted that the frequency with which craniotomy has been per- 
formed in England constitutes a great blot on British midwifery. Dur- 
ing the mastership of Dr. Labbat at the Rotunda Hospital the forceps 
was never once applied in 21,867 labors. Even in the time of Clarke 
and Collins, when its frequency was much diminished, craniotomy was 



OPERATIONS INVOLVING DESTRUCTION OF THE FCETUS. 505 

performed three or four times as often as forceps delivery. These fig- 
ures indicate a destruction of foetal life which we cannot look back to 
without a shudder, and which, it is to be feared, justify the reproaches 
which our continental brethren have cast upon our practice. Fortu- 
nately, professional opinion has now completely recognized the sacred 
duty of saving the infant's life whenever it is practicable to do so ; and 
British obstetricians now teach as carefully as those of any other nation 
the imjierative necessity of using every endeavor to avoid the destruc- 
tion of the foetus. 

Divisions of the Subject. — The operation now under consideration 
may be necessary — 1st, when the head requires either to be simply per- 
forated or afterward more completely broken up and extracted — an ope- 
ration which has received various names, but is generally known in 
England as craniotomyy and which may or may not require to be fol- 
lowed by further diminution of the trunk ; 2dly, when the arm presents 
and turning is impossible : this necessitates one of two procedures — 
decapitation, with the separate extraction of the body and head, or evis- 
ceration. [Or, what is equally promising in such cases, where the 
woman has had no deforming disease and is far less difficult of execu- 
tion, the conservative Csesarean section. — Ed.] In both classes of cases 
similar instruments are employed, and those generally in use at the pres- 
ent time may be first briefly described. 

Instruments Employed. — 1. The object of the perforator is to 
pierce the skull of the child, so as to admit of the brain being broken 
up and the consequent collapse and diminution in size of the cranium. 
The perforator invented by Denman or some modification of it has been 



Fig. 181. 



Fig. 182. 



Fig. 183. 




Various Forms of Torforators. 



principally employed. It requires the handles to bo separated in onUn- 
to open tlie blades, and this cannot be done by the i>|>erator hinisclt'. 
Tliis dilticulty is overcome in the modilication of Naegvle's perforator 



506 



OBSTETRIC OPERA TIOXS. 



used in Edinburgh, in which the handles are so constructed that they 
open the points when pressed together, and are separated by a steel rod 
with a joint at its centre to prevent their opening too soon. By this 
arrangement the instrument can be manipulated by one hand only. The 
sharp-pointed portion has an external cutting edge, with projecting 
shoulders at its base to prevent its penetrating too far into the cranium. 
Many modifications of these arrangements have since been contrived 
(Figs. 181, 182, 183). In some parts of the Continent a perforator is 
used constructed on the principle of the trephine, but this is vastly 
more diificult to work, and has the great disadvantage of simply boring 
a hole in the skull, instead of splitting it up as is done by the sharp- 
pointed instrument. 

Crotchets and Craniotomy Forceps. — The instruments for extrac- 
tion are the crotchet and craniotomy forceps. 

The crotchet is a sharp-pointed hook of highly-tempered steel Avhich 
can be fixed on some portion of the skull, either internal or external, 
traction being made by the handle. The shank of the instrument is 
either straight or curved (Figs. 184 and 185), the latter being prefer- 
able, and it is either attached to a wooden handle or 
Figs. 184, 185. forged in a single piece of metal. A modification of 
^j. this instrument is known as Oldham^s vertebral hook. 

V^ It consists of a slender hook, measuring with its han- 

a die 13 inches in length, which is passed through the 

foramen magnum and fixed in the vertebral canal, so 
as to secure a firm hold for traction. All forms of 
crotchets are open to the serious objection of being 
liable to slip or break through the bone to which they 
are fixed, so wounding either the soft parts of the 
mother or the fingers of the operator placed as a 
guard. Hence they are discountenanced by most re- 
cent writei^, and may with propriety be regarded as 
obsolete instruments. 

Their place as tractors is well supplied by the more 
modern craniotomy forceps (Fig. 186). These are 
intended to lay hold of the skull, one blade being 
introduced within the cranium, the other externally, 
and when a firm grasp has been obtained downward 
traction is made. A second object it fulfils is to 
break away and remove portions of the skull when 
perforation and traction alone are insufficient to effect 
delivery. Many forms of craniotomy forceps are in 
use — some armed with formidable teeth ; others, of 
simpler construction, depending on their roughened 
and serrated internal surfaces for firmness of grasp. 
For oeneral use there is no better instrument than 
the cranioclast of Sir James Simpson (Fig. 187), which admirably ful- 
fils both these indications. It consists of two separate blades fastened 
by a button joint. The extremities of the blades are of a duck-billed 
shape, and are sufficiently curved to allow of a firm grasp of the skull 
being taken : the upper blade is deeply grooved to allow the lower to 




Crotchets. 



OPERATIONS INVOLVING DESTRUCTION OF THE FOETUS. 507 

sink into it, and this gives the instrument great power in fracturing the 
cranial bones wlien that is found to be necessary. It need nrjt, how- 
ever, be employed for the latter purpose, and, the blades being serrated 
on their under surface, form as perfect a pair of craniotomy forceps as 



Fig. 186. 



Fig. 187. 





CraniotoEiy Forceps. 



Simpson's Cranioclast. 



any in ordinary use. Provided with it, we are spared the necessity of 
procuring a number of instruments for extraction. 

Cephalotribe. — Amongst modern improvements in midwifery there 
are few which have led to more discussion than the use of the cephalo- 
tribe. This instrument, originally invented by Baudelocque, was long 
employed on the Continent before it was used in Great Britain, the prej- 
udice against it being no doubt due to its formidable size and ap})ear- 
ance. Of late years many of our leading obstetricians have used it in 
preference either to the crotchet or craniotomy forceps, and have materi- 
ally modified and improved its construction, so that the most objection- 
able features of the older instrument are now entirely rem('>ved. 

The Instrument. — The cepludotribe consists of two ]Hnverful solid 
blades which are applied to the head after perforation and approximated 
by means of a screw so as to crush the cranial bones, and alter this it 
may be also used for extraction. The peculiar value of the iiistruuiont 
is that when properly applied it crushes the iirm base of the skull, 
which is left untouched by craniotomy, or if it does not it at least causes 
the base to turn edgeways within the blades, so as to be in a more favor- 
able position for extraction. Another and specially valuable property 
is that it crushes the bones irif/u'n the seal{>, ^^■hieh Ibiins a most etUcient 
protective covering to their sharp edges. In this way one ot' the prin- 
cipal dangers of craniotomy — tlu> woinuling ot' the maternal passiiges 
bv spieida' of bone — is entirely avoided. 

The cephalotribe, therefore, acts in two ways — as a eruslu r and as a 



608 



OBSTETRIC OPERA TIOXS. 



tractor. Some obstetricians believe the former to be its more important 

use, and even maintain that the cephalo- 
tribe is unsuited for traction. This view 
is specially maintained by Pajot, who 
teaches that after the size of the skull 
has been diminished bv repeated crush- 
ings its expulsion should be left to the 
natural powers. There are some grounds 
for believing that in the greater degrees 
of obstruction the tractile power of the 
instrument should not be called into 
use, but in the large majority of cases 
the facility with which the crushed head 
may be withdrawn by it constitutes one 
of its chief claims to the attention of 
the obstetrician. Xo one who has used 
it in this way, and experienced the rapid 
and easy manner in which it accom- 
plishes delivery, can have any doubt 
on this point. 

There is every reason to believe that 
cephalotripsy will be much extended in 
Great Britain, and that it will be con- 
sidered, as I believe it uucjuestionably 
deserves to be, the ordinary operation in 
cases requiring destruction of the foetus. 
The comparative merits of cephalotripsy 
and craniotomy will be subsequently 
considered. 

The most perfect cephalotribe is prob- 
ably that known as Braxton Hicks' 
(Fig. 188), which is a modification of 
Simpson's. It is not of unwieldy size, but suf&ciently powerful for any 
case, and not extravagant in price. The blades have a slight pelvic 
curve, which materially facilitates their introduction, yet not sufficiently 
marked to interfere with their being slightly rotated after application. 
Dr. Kidd of Dublin prefers a straight blade, while Dr. Matthews Dun- 
can thinks it better to use a somewhat bulkier instrument, modelled on 
the type of the continental cephalotribes. The principle of action of 
all these is identical, and their differences are not of very material 
importance. 

Section of the Skull by the Forceps Saw or Bcraseur. — An- 
other mode of diminishing the fcetal skull is by removing it in sections. 
The object is aimed at in the forceps saw of Van Huevel, which con- 
sists of two large blades, not unlike those of the cephalotribe in appear- 
ance. Within these there is a complicated mechanism working a chain- 
saw from below upward, which cuts through the fcetal skull ; the sep- 
arated portions are subsequently withdrawn piecemeal. This instrument 
is highly spoken of by the Belgian obstetricians, Avho believe that it 
affords by far the safest and most effectual wav of reducing the bulk of 




Hicks' Cephalotribe. 



OPERATIONS INVOLVING DESTRUCTION OF THE F(ETUS. 509 

the foetal skull. In England it is practically unknown, and, although 
it must be admitted to be theoretically excellent, the complexity and cost 
of the apparatus have always stood in the way of its being used. 

Dr. Barnes has suggested that the same results may be obtained by 
dividing the head with a strong wire ^craseur. So far as I know, this 
suggestion has never yet been carried out in practice, not even by him- 
self, and therefore it is not possible to say much about it. I should 
imagine, however, that there would be considerable difficulty in satis- 
factorily passing the loop of wire over the skull in a pelvis in w^hich 
there is any well-marked deformity. 

Cases requiring" Craniotoniy. — The most common cause for which 
craniotomy or cephalotripsy is performed is a want of proper proportion 
between the head and the maternal passages. This may arise from a 
variety of causes. The most important, and that most often necessitat- 
ing the operation, is osseous deformity. This may exist either in the 
brim, cavity, or outlet, and it is most often met Avith in the antero- 
posterior diameter of the brim. Obstetric authorities differ consider- 
ably as to the precise amount of contraction which will prevent the 
passage of a living child at term. Thus, Clarke and Burns believe 
that a living child cannot pass through a pelvis in which the antero- 
posterior diameter at the brim is less than 3J inches. Ramsbotham 
fixes the limit at 3 inches, and Osborne and Hamilton at 2f inches. 
The latter is the extreme limit at which the birth of a living child is 
possible ; but there can be no doubt that under favorable circumstances 
it may be possible to draw the foetus, after turning, through a pelvis of 
that size. The opposite limit of the operation is still more open to dis- 
cussion. Various authorities have considered it quite possible to draw 
a mutilated foetus through a pelvis in which the antero-posterior diam- 
eter does not exceed IJ inches, and indeed have succeeded in doing so. 
But then there must be a fair amount of space in the transverse diam- 
eter of the pelvis to admit of the necessary manipulations. If tliere 
be a clear space here of 3 inches and upward, it is no doubt possible to 
deliver per vias naturales ; but in such extreme deformities the difficul- 
ties are so great, and the bruising of the maternal structures so exten- 
sive, that it becomes an operation of the greatest possible severity, with 
results nearly as unfavorable to the mother as the Ca\<arean section. 
Hence some continental authorities have not scrupled to prefer the latter 
operation in the worst forms of pelvic deformity. The rule in English 
practice always has been that craniotomy nuist be performed wluMievor 
it is practicable and there can be no doubt that it is the right one. 

Between from 2J to 3 inches antero-posterior diameter in the one 
direction, \} inches in the other, may be said to be the limits of crani- 
otomy, provided, in the latter case, there be a fair amount of space in 
the transverse diameter. The same limits may be laid down with regard 
to tumors or other sources of obstruction. 

There are a few other conditions in which craniotomy is jnsiitiable, 
independently of pelvic contraction, such as certain changes in the 
soft j)arts which are supposed to render the passage of ihe head peculiarly 
dangerous to the motluM*. Among them may be mentioned swelling 
and inlianunation of the vagina iVoni the length o( the previons labor. 



610 OBSTETRIC OPERATIONS. 

bands and cicatrices of the vagina, and occlusion and rigidity of the os. 
It is hardly too much to say that with a proper use of the resources of 
midwifery the destruction of a living foetus for any of these conditions 
may be obviated. The most common of them is undoubtedly swelling 
of the soft parts, causing impaction of the head — an occurrence which 
ought to be invariably prevented by a timely use of the forcejjs. Should 
interference unfortunately be delayed until impaction has actually taken 
place, doubtless no other resource but craniotomy would be left ; but 
such cases, it is to be hoped, are now of rare occurrence in British prac- 
tice. Undue rigidity of the os can be overcome by dilatation with the 
caoutchouc bags, or in more serious cases by incision, which would cer- 
tainly be less perilous to the mother than dragging even a mutilated 
foetus through the small and rigid aperture. In the case of bands and 
cicatrices in the vagina, dilatation or incision will generally suffice to 
remove the obstruction ; but even were this not so, here, as in excessive 
rigidity of the perineum, it w^ould be better that slight lacerations should 
take place than that the child should be killed. 

Certain complications of labor are held to justify craniotomy, 
such as rupture of the uterus, convulsions, and hemorrhage. The 
application of the forceps or turning will generally answer our purpose 
equally well, especially as we have the means of dilating the os suffici- 
ently to admit of one or other of them being performed when the natural 
dilatation is not sufficient. Craniotomy in rupture of the uterus will 
also be rarely indicated, as we have seen that gastrotomy appears to 
affiDrd a better chance to the mother in those cases in which the foetus 
has partially or entirely escaped from the uterine cavity. 

Want of proportion between the foetus and the pelvis, depending on 
undue size of the head, either natural or the result of disease, may 
render the operation essential. In the former of these cases we shall 
generally have first attempted delivery with the forceps, and if it has 
failed, there can be no doubt as to the propriety of lessening the bulk 
of the head by perforation. 

In most obstetric works we are recommended to perforate rather than 
apply the forceps when we are convinced that the child has ceased to 
live. This advice is based on the greater facility with which craniotomy 
can be performed, and its supposed greater safety to the mother. There 
can be no doubt of the ease with which the child can be extracted after 
perforation w^hen the pelvis is not contracted, and if we could always 
be sure of our diagnosis, the rule might be a good one. Before acting 
on it, however, we must bear in mind the extreme difficulty of posi- 
tively ascertaining the death of the foetus. Of the signs usually relied 
on for this purpose, there are scarcely any which are not open to fallacy, 
except peeling of the scalp and disintegration of the cranial bones, which 
do not take place unless the child has been dead for a length of time, 
and are therefore useless in most instances. Discharge of the meconium 
constantly takes place when the child is alive ; a cold and pulseless pro- 
lapsed cord may belong to a twin ; and a foetal heart may become 
temporarily inaudible although the child is not dead. If, indeed, we 
have carefully watched the foetal heart all through the labor, and heard 
it become more and more feeble, and finally stop altogether, we might 



OPERATIONS INVOLVING DESTRUCTION OE THE FOETUS. hU. 

be certain that the child has died ; but surely such observations would 
rather indicate an early recourse to the force|)s or version so as to obviate 
the fatal result we know to be imj)ending;. 

Perforation of the After-coming* Head. — In certain breech j)res- 
entations or after turning it may be found impossible to extract the 
head without diminishing its size by perforating behind the ear. In 
such cases we know to a certainty whether the child be alive or dead 
before resorting to the operation. 

The first step, whether we resort to cephalotripsy or craniotomy, is 
perforation, which will therefore be first described. In the former tlie 
desirability of first perforating the head is not always recognized. To 
endeavor to crush the head without perforating is needlessly to increase 
the difficulties of the case, and it should be remembered as a cardinal 
rule that perforation is an essential preliminary to the proper use of 
the cephalotribe. 

Before perforating we must carefully ascertain the exact relation of 
the OS to the presenting part, since in many cases the operation is per- 
formed before the os is fully dilated, when there is a risk of wounding 

Fig. 189. 




Porforation of tho Skull. 



the cervix. Two or nlore fingers ol" (he Icl'i luuui should bo p:is,-oil up 
to the head, and placed against tlu> most ]>roiniuent part oi^ the parietal 
bone. Under these, used as a guard (^Fig. 189), the perforator should 



512 OBSTETRIC OPERATIONS. 

be cautiously introduced until the scalp is reached. It is important to 
fix on a bony part of the skull, and not on a suture or fontanelle, for 
puncture, because our object is to break up the vault of the cranium as 
much as possible, so as to allow the skull to collapse. When the instru- 
ment has reached the point we have selected, it should* be made to pene- 
trate the scalp and skull Avith a semi-rotatory boring motion, and 
advanced until it has sunk up to the rests, which will oppose its far- 
ther progress. Occasionally considerable force will be necessary to 
effect penetration, more especially if the scalp be swollen by long- 
continued pressure ; and this stage of the operation will be facilitated 
by causing an assistant to steady the head by pressure on the foetus 
throngh the abdomen, more especially if it be still free above the 
pelvic brim. We must then press together the handles of the instru- 
ment, which will have the effect of widely separating the cutting 
portion and making an incision through the bones. After this the 
point should be turned round, and again opened at right angles to 
the former incision, so as to make a free crucial opening. During this 
process care must be taken to bury the perforator in the skull up to the 
rests, so as to avoid the possibility of injuring the maternal soft parts. 
The instrument should now be introduced within the skull and moved 
freely about, so as to thoroughly and completely break up the brain. 
Especial care must be taken to reach the medulla oblongata and base 
of the brain, for if these are not destroyed we may subject ourselves 
to the distress of extracting a child in whom life was not extinct. If 
this part of the operation be thoroughly performed, there will be no 
necessity for washing out the brain by the injection of warm water, as 
is sometimes recommended, for the broken-up tissue will escape freely 
through the opening made by the perforator. 

The perforation of the after-coming head does not generally oiFer any 
particular difficulty. It is accomplished in the same manner, the child's 
body being well drawn out of the way by an assistant. The point of 
the perforator, carefully guarded by the finger, is guided up to the occi- 
put or behind the ear, where it is inserted. 

If there be no necessity for very rapid delivery, and the pains be still 
present, it is often advisable to wait ten minutes or a quarter of an hour 
before proceeding to extract. This delay will allow the skull to collapse 
and become moulded to the cavity of the pelvis when forced down by 
the pains, and possibly the natural efforts may suffice to finish the labor 
in that time ; or at least the head will have descended farther and will 
be in a better position for extraction. Should perforation be required 
after having failed to deliver with the forceps — and this is only likely 
to be the case when the obstruction is comparatively slight — it is cer- 
tainly a good plan to perforate without removing the forceps, which 
may then be used as a tractor. 

We have now to decide on the method of extraction, and our choice 
generally lies between the cephalotribe and the craniotomy forceps, 
although in some few cases, in which the pelvic contraction is slight, 
version may be advantageously employed. 

Comparative Merits of Cephalotripsy and Craniotomy. — Those 
who have used both must, I think, admit that in any ordinary case, in 



OPERATIONS INVOLVING DESTRUCTION OF THE FCETUS. 513 

which the obstruction is not great and only a comparatively slight 
diminution in the size of the head is required, cephalotripsy is infinitely 
the easier operation. The facility with which the skull can be crushed 
is sometimes remarkable, and those who will take the trouble to read 
the reports of the operation published by Braxton Hicks, Kidd, and 
others cannot fail to be struck with the rapidity with which the broken- 
down head may often be extracted. This is far from being the case with 
the craniotomy forceps, even when the obstruction is moderate only ; for 
it may be necessary to use considerable traction, or the blades may take 
a proper grasp with difficulty, or it may be essential to break down and 
remove a considerable portion of the vault of the cranium before the 
head is lessened sufficiently to pass. During the latter process, how- 
ever carefully performed, there is a certain risk of injuring the mater- 
nal structures, and in the hands of a nervous or inexperienced operator 
this danger, which is entirely avoided in cephalotripsy, is far from slight. 
The passage of the blades of the cephalotribe is by no means difficult, 
and I think it must be admitted that the possible risks attending it are 
comparatively small. On account, therefore, of its simplicity and safety 
to the maternal structures, I believe cephalotripsy to be decidedly the 
preferable operation in all cases of moderate obstruction. 

When we approach the lower limit and have to do with a very 
marked amount of pelvic deformity, the two operations stand on a more 
equal footing. Then the deformity may be so great as to render it dif- 
ficult to pass the blades of even the smallest cephalotribe sufficiently 
deep to grasp the head firmly, and even when they are passed the space 
is often so limited as to impede the easy working of the instrument. 
Besides this, repeated crushings may be required to diminish the skull 
sufficiently. I attach but little importance to the argument that the 
diminution of the skull in one diameter increases its bulk in another. 
The necessity of removing and, replacing the blades on another part of 
the skull, and of repeating this perhaps several times, in the manner 
recommended by Pajot, is a far more serious objection. To do this in 
a contracted pelvis involves, of necessity, the risk of much contusion. 
Fortunately, cases of this kind are of extreme rarity, much more so than 
is generally believed, but when they do occur they tax the resources of 
the practitioner to the utmost. 

On the whole, the conclusion I would be inclined to arrive at with 
regard to the two operations is that in all ordinary cases cephalotripsy 
is safer and easier, whereas in cases with considerable pelvic deformitv 
the advantages of cephalotripsy are not so well marked, and craniotomy 
may even prove to be ]H-eferable. 

The first step in using the cephalotribe is the passage of the blades. 
These are to be inserted in precisely the same manner and with the same 
precautions as in the high-forceps operation. In many cases the os is 
not fully dilated, and it is absolutely essential to pass the instrument 
within it. Special care should therefore be taken to avoid any injury 
to its edges, an'd for this purpose two or three fingers of the leit hand, 
or even the whole hand, should be passed high \\\\, so as thorouehlv to 
protect the maternal structures. In order that the base o( the skull may 
be reached and efieetually crushed the blades must be deeply inserted, 

Z'6 



514 



OBSTETRIC OPERATIONS. 



Fig. 190. 



and in doing this great care and gentleness must be used. As the pro- 
jecting promontory of the sacrum generally tilts the head forward, the 
handles of the instrument, after locking, must be well pressed back- 
ward toward the perineum. If the blades do not lock easily or if any 
obstruction to their passage be experienced, one of them must be with- 
drawn and reintroduced, just as in forceps operations. Care must be 
taken, as the instrument is being inserted, to fix and steady the head 
by abdominal pressure, since it is generally far above the brim, and 
would readily recede if this precaution were neglected. When the 
blades are in situ we proceed to crush by turning the screw slowly, and 
as the blades are approximated the bones yield and the cephalotribe 
sinks into the cranium. The crushed portion then measures, of course, 
no more than the thickness of the blades, that is, about H inches. 
This is necessarily accompanied by some bulging of the part of the 
cranium that is not within the grasp of the instrument (Fig. 190), but 
in slight deformity this is of no consequence, and w^e may proceed to 
extraction, waiting, if possible, for a pain, and drawing at first down- 
ward in the axis of the pelvic inlet, as in forceps delivery, then in the 

axis of the outlet. The site of perforation 
should be examined to see that no spiculae 
of bone are projecting from it, and if so they 
should be carefully removed. In such cases 
the head often descends at once and with the 
greatest ease. Should it not do so or should 
the obstruction be considerable, a quarter 
turn should be given to the handles of the 
instrument, so as to bring the crushed por- 
tion into the narrower diameter and the 
uncrushed portion into tlie wider transverse 
diameter. It may now be advisable to re- 
move the blades carefully, and to reintro- 
duce them with the same precautions, so as 
to crush the unbroken portion of the skull. 
This adds materially to the difficulties of the 
case, since the blades have a tendency to fall 
into the deep channel already made in the 
cranium, and so it is by no means always 
easy to seize the skull in a new direction. 
Before reapplying them, if the condition of 
the patient be good and pains be present, it 
may be w^ell to wait an hour or more, in the 
hope of the head being moulded and pushed 
down into tlie pelvic cavity. This was the 
plan adopted by Dubois, and, according to 
Tarnier, was the secret of his great success 
in the operation. Pajot's method of repeated 
crushing in the greater degrees of contrac- 

Foetal Head^Crushed by the ^-^^^ -^ ^^^^^ ^^^ ^j^^ g^^^^^ -^1^,^^ ^^^j j^g ^.^^^^-^^_ 

mends that the instrument should be intro- 
duced at intervals of two, three, or four hours, according to the state of 




OPERATIONS INVOLVING DESTRUCTION OF THE FCETJJS. ol^ 



Fig. 191. 



the patientj until the head is thoroughly crushed, uo attempts at traction 
being used and expulsion being left to the natural powers. This, he 
says, should always be done when the contraction is below 2J inches, 
and he maintains that it is quite possible to effect delivery by this means 
when there are only IJ inches in the antero-posterior diameter. The 
repeated introduction of the blades in this fashion must necessarily be 
hazardous, except in the hands of a very skilful operator ; and I believe 
that if a second application fail to overcome the difficulty, which will 
only be very exceptionally the case, it would be better to resort to the 
measures presently to be described. 

Professor Simpson of Edinburgh ^ has recently suggested the use of 
an instrument which he calls a " basilyst." Its object is to break up 
the base of the foetal skull from within, after the method 
originally proposed by Guyon. The screw-like portion 
of the instrument (Fig. 191), which is inserted through 
the perforation made in the cranial vault, is driven 
through the hard base, which is then disintegrated by 
the separate movable blade. If experience proves that 
this instrument can be readily worked, it promises to 
be a valuable addition to our armamentarium, since it 
will effectually destroy the most resistant portion of the 
skull without risk of injury to the maternal structures, 
and thus very materially facilitate extraction. 

Extraction by the Craniotomy Forceps. — Should 
we elect to trust to the craniotomy forceps for extraction, 
one blade is to be introduced through the perforation, 
and the other, in apposition to it, on the outside of the 
scalp. In moderate deformities traction applied during 
the pains may of itself suffice to bring down the head. 
Should the obstruction be too great to admit of this, it 
is necessary to break down and remove the vault of the 
cranium. For this purpose Simpson's cranioclast 
answers better than any other instrument. One of the 
blades is passed within the cranium, the other, if possible, between the 
seal]) and the skull, and the portion of bone grasped between them is 
broken off; this can generally be accomplished by a twisting motion of 
tJie wrist without using nmcli force. The separated portion of bone is 
then extracted, the greatest care being taken to guard the maternal 
structures during its removal by the fingers of the left hand. The 
instrument is then applied to a fresh part of the skull and tiie same ])ro- 
cess repeated, until as much of the vault of the cranium as may be neces- 
sary is broken up and removed. 

Dr. Braxton Hicks^ has conclusively shown that in ditlit'uh cases. 
after the removal of the cranial vault, the ])roper procedure is to bring 
down the face, since the smallest measurement of the skull after the 
removal of the up|)er part of the cranium is from the orbital ridge to 
the alveolar edge of the superior maxillary bone. This alteration in 
tlu^ presentation he pniposes to effect by a small blunt lu^ok made for 
the ptirpose, which is forced into the orbit, by means of which the facv 
' Edin. Mvd, Jouni., vol. 1879-80, p. 805. ^ Obst. Tratu-i., 18G7. vol. vii. p. 57. 



Professor Simpson's 
Basilvst. 



516 



OBSTETRIC OPERATIONS. 



Fig. 192 



Fig. 



is made to descend. Barnes recommends that this should be done by 
fixing the craniotomy forceps over the forehead and face, and making 
traction in a backward direction, so as to get the face past the projecting 
promontory of the sacrum. The importance of bringing down the face 
was long ago pointed out by Burns, but it had been lost sight of until 
Hicks again drew attention to it in the paper referred to. In the class 
of cases in which this procedure is valuable the risk to the maternal 
passages from the removal of the fractured portions of bone must always 
be considerable, and it is of great importance not only to preserve the 
scalp as entire as possible, so as to protect them, but to use the utmost 
possible care in removing the broken pieces of bone. 

Extraction of the Body. — When the extraction of the head has 
been effected, either by the cephalotribe or the craniotomy forceps, there 
is seldom much difficulty with the body. By traction on the head one 
of the axillae can easily be brought within reach, and if the body do 
not readily pass, the blunt hook should be introduced and traction made 
until the shoulder is delivered. The same can then be done with the 
other arm. If there be still difficulty the cephalotribe may be used to 
crush the thorax. The body is, however, so compressible that this is 
rarely required. 

[The craniotomy forceps chiefly in use with us 
were devised by the late Prof. Charles D. Meigs 
for his second operation upon Mrs. Beybold of 
Philadelphia in 1833, and have been used re- 
peatedly since, either as tractors or for reducing 
the size of the foetal head, in cases of deformity 
of the pelvis.^ Some obstetricians prefer the less 
curved and broader-bladed instrument of Great 
Britain as a tractor ; but for the general purposes 
of picking away the cranial bones and drawing 
down the base of the skull in cases of extreme 
pelvic deformity there is no more simple appli- 
ance than that of Dr. ^Nleigs. 

To act upon an oval body like the foetal head 
Dr. M. was obliged to prepare two forms of for- 
ceps — straight and curved— to be used as might 
be required according to the part of the skull 
to be broken down or drawn upon. These are 
lightly made, serrated, and 12 J inches in length. 
—Ed.] 

Erabryotomy. — There only remains for us to 
consider the second class of destructive operations. 
These may be necessary in long-neglected cases 
of arm presentation in which turning is found to be impracticable. Here, 
fortunately, the question of killing the foetus does not arise, since it will, 
almost necessarily, have already perished from the continuous pressure. 
We have two operations to select from — decapitation and evisceration, 

\} The illustrations given are taken from the instruments devised by Dr. Meigs as an 
improvement upon his original pattern, and will be seen to differ from those usually 
presented in American obstetrical publications.— -Ed.] 




Straight Curved 

Craniotomy Craniotomy 

Forceps. Forceps. 



OPERATIONS INVOLVING DESTRUCTION OF THE FCETUS, 517 

The former of these is an operation of great antiquity, having jjeen 
fully described by Celsus. It consists in severing the neck, so as to 
separate the head from the body ; the body is then withdrawn by means 
of the protruded arm, leaving the head in utero, to be subsequently 
dealt with. If the neck can be reached without great difficulty — and 
in the majority of cases the shoulder is sufficiently pressed down into 
the pelvis to render this quite possible — there can be no doubt that it is 
much the simpler and safer operation. 

The whole question rests on the possibility of dividing the neck. 
For this purpose many instruments have been invented. The one 
generally recommended in England is known as Ramsbotham's hook, 
and consists of a sharply curved hook with an internal cutting edge. 
This is guided over the neck, which is divided by a sawing motion. 
There is often considerable difficulty in placing the instrument over the 
neck, although if this were done it would doubtless answer well. Others 
have invented instruments based on the principle of the apparatus for 
plugging the nostrils, by means of which a spring is passed round the 
neck, and to the extremity of the spring a short cord or the chain of 
an ecraseur is attached ; the spring is then withdrawn and brings the 
chain or cord into position. The objection to any of these apparatuses 
is tliat they are unlikely to be at hand when required, for few practi- 
tioners provide themselves with costly instruments which they may 
never require. It is of importance, therefore, that we should have at 
our command some means of dividing the neck which is available in 
the absence of any of these contrivances. Dubois recommends for this 
purpose a strong pair of blunt scissors. The neck is brought as low as 
possible by traction on the prolapsed arm, and the blades of the scissors 
guided carefully up to it. By a series of cautious snipping movements 
it is then completely divided from below upward. This, if the neck 
be readily within reach, can generally be effected without anv particular 
difficulty. Dr. Kidd of Dublin,^ who strongly advocates this operation, 
recommends that an ordinary male elastic catheter, strongly curved and 
mounted on a firm stilet, or, still better, on a uterine sound, should be 
passed round the neck. Previous to introduction a cord should be 
passed through the eye of the catheter, which is left round the neck 
when it is withdi'awn. By means of this cord a strong piece of whip- 
cord or the wire of an ecraseur can easily be drawn round the neck ami 
used for dividing it. The former, to protect the maternal structures, 
may be worked through a speculum, and by a series of lateral move- 
ments the neck is easily severed. The ecraseur, however, offers special 
advantage, since it entirely does away Avith any risk of injuring the 
mother. 

Withdrawal of the Body and Delivery of the Head. — Alter the 
neck is divided the remainder of the operation is easv. The bodv is 
withdrawn without difficidty by the arm, and we then proceed to deliver 
tlu^ head. By abdominal pressure this in most cases can be pushed 
down into the pelvis, so as to come easily within reach o( the cephalo- 
tribe, which is by far the best instrument for extraction. Preliminary 
})erforation is not necessary, since the brain i-an escape through the 
' Dublin Quart. Jouini. of M\\l. S'icitcr, 1S71. vol. li. v. [^$o. 



518 OBSTETRIC OPERATIOyS. 

severed vertebral canal. The secret of doing this easily is to fix and 
press down the head sufficiently from above, other^vise it would slip 
away from the grasp of the instrument. The perforator and craniotomy 
forceps may be used if the cephalotribe be not at hand. Perforation is, 
however, h\ no means always easy, on account of the mobility of the 
head. After it is accomplished one blade of the craniotomy forceps is 
passed within the skull, the other externally, and the head slowly 
drawn down. 

Evisceration. — The alternative operation of evisceration is a much 
more troublesome and tedious procedure, and should only be used when 
the neck is inaccessible. The first step is to perforate the thorax at its 
most depending part, and to make as wide an opening into it as possi- 
ble in order to gain access to its contents. Through this the thoracic 
viscera are removed piecemeal, being first broken up as much as possi- 
ble by the perforator, and then, the diaphragm being penetrated, those 
in the abdomen. The object is to allow the body to collapse and the 
pelvic extremities to descend as in spontaneous evolution. This can be 
much facilitated by dividing the spinal column with a strong pair of 
scissors introduced into the opening made in the thorax, so that the 
body may be doubled up as on a hinge. Here the crotchet may find a 
useful application, for it can be passed through the abdominal cavity 
and fixed on some point in the interior of the child's pelvis, and thus 
strong traction can be made without any risk of injury to the mother. 
It can be readily understood that this process is so lengthy and difficult 
as to render it probably the most trying of obstetric operations ; it is cer- 
tainly inferior in every respect to decapitation, and is only to be resorted 
to when that is impracticable. 



CHAPTER YI. 



THE CESAREAN SECTION— POEEO'S OPEKATION. 
SYMPHYSIOTOMY. 

History of the Csesarean Section. — The Caesarean section has per- 
haps given rise to more discussion than any other subject connected 
with midwifery, and there is yet much difference of opinion as to 
the limits of, and indications for, the operation. The period at which 
Csesarean section was first resorted to is not known with accuracy .- 
It seems to have been practised by the Greeks after the death of the 
mother, and Pliny mentions that Scipio Africanus and Manlius were 
born in this way. The name of Caesar is said to have been given to 
children so extracted, and afterward to have been assumed as a family 
patronymic. These children were dedicated to Apollo, whence arose 



THE CJESAREAN SECTION. 519 

the practice of things sacred to that god being taken under tlje 
special protection of the family of the Csesars. Many celebrities have 
been supposed to owe their lives to the operation, among the rest 
^Esculapius, Julius Csesar, and Edward VI. of England. Regarding the 
two latter, there Is conclusive proof tliat the tradition is without founda- 
tion. There is no doubt that the operation was constantly practised 
on women who had died at an advanced period of pregnancy, and 
indeed it has at various times been enforced by law. Thus, among the 
Romans it was decreed by Numa that no pregnant woman should be 
buried until the foetus had been removed by abdominal section. The 
Italian laws also made it necessary, and the operation has always receiv- 
ed the strong support of the Roman Church. So lately as the middle 
of the eighteenth century the king of Sicily sentenced to death a phy- 
sician who had neglected to practise it. The first authentic case in 
which the operation was performed on a living woman occurred in 
1491. It was afterward practised by Nufer in 1500 [^] ; and in 1581, 
Rousset published a work on the subject in which a number of success- 
ful cases were related. In English works of that time it is not alluded 
to, although it was undoubtedly performed on the Continent, and to 
such an extent that its abuse became almost proverbial. We have 
evidence in Shakespeare, however, that the operation was familiarly 
known in Great Britain, since he tells us that — [^J 

" . . . . MacdnfF was from his mother's womb 
Untimely ripped." 

Pare and Guillemeau, amongst the writers of the period, were noted for 
their hostility to the operation, while others equally strongly upheld it. 
In England it has scarcely ever been performed in a manner which 
oifers even the faintest hope of success. It has been looked upon as 
almost necessarily fatal to the mother, and it has therefore been delaved 
until the patient has arrived , at the utmost stage of exhaustion. For 
example, in looking over the record of British cases it is no uncommon 
thing to find that the Caisarean section was resorted to two, three, or 
even six days after labor had begun, and when the patient was almost 
moribund. With rare exceptions within the last few years the opera- 
tion has been performed in what may be called a haphazard Avav. In 
many cases long and fruitless attempts at delivery by craniotomy had 
already been made, so that the passages had been subjected to nuich 
contusion and violence. Little or no attempt has been made to obvi- 
ate the well-known risks of abdominal operations ; no care has beiMi 
taken to prevent blood and other fluids finding their way into tlio 
peritoneal cavity; and no means have been adopted subsequent I v td 
remove them. It is, therefore, not so nuich a matter (^{^ surprise that 
the mortality has been so great, but rather that any eases have 

• f Prob.-ibly in 1498; the boy deli vorod livcil to be sevonty-sovon yo;u-s old ; caK'u- 
hilino- backward gives this date. Rousset says, " about ti\e year loOO." — Kd.] 

['^ Ilolinshed, ibe liislorian, (1577), makes MacdutV say, *' 1 was ripi^ed out."' Mrs. 
Maodufl" was probably opeuated on by a ooav. Horned eattle have performed the 
operation 11 times since 1()U>. with a lossof 3 women and (> children; one case in Kdin- 
buro-h resulted favorably to both mother antl child. Three male MainluHs are proba- 
bly now living in North America; one, of twenty-one, is at West Toiut.— Ei\] 



520 OBSTETRIC OPERATIONS. 

recovered. [This does not apply to the maiiagemeDt of several recent 
operations. — Ed.] 

From what we know of the history of ovariotomy, its early fatality, 
and the extreme and even apparently exaggerated precautions which are 
essential to its success, it is fair to conclude that if the Cfesarean section 
were performed, as it is to be hoped it always will be in future, with the 
same careful attention to minute details as ovariotomy, the results would 
not be so disastrous. Making every allowance for these facts, it must 
be admitted that the Csesarean section, as hitherto performed, has been 
necessarily almost a forlorn hope, although, happily, recent statistics 
show that this need no longer be considered the case. In making these 
observations I have no intention of contesting the well-established rule 
of British practice that it is not admissible as an operation of election, and 
must only be resorted to when delivery iper vias naturales is impossible-. 

Statistical Returns not Reliable. — The mortality, as given in sta- 
tistical returns from various sources, differs so greatly as to make them 
but little reliable. Radford has tabulated the operations performed in 
Great Britain up to 1879, [^] and the list has been completed by Harris 
up to 1889. The cases amount to 154 in all, of which 32 were success- 
ful. Michaelis and Kayser found that out of 258 cases and 338 opera- 
tions, 54 and 64 per cent., respectively, were fatal. These include 
operations performed under all sorts of conditions, even when the 
patient was almost moribund ; and until we are in possession of a 
sufficient number of cases performed under conditions showing that 
the result is certainly due to the operation — in which it was under- 
taken at an early period of labor and performed with a reasonable 
amount of care — it is obviously impossible to arrive at any reliable 
conclusions as to the mortality of the operation. [The Csesarean sta- 
tistics of the past, with the exception of those of the years 1885, 1886, 
1887, and 1888, are of wery little real value in calculating the present 
dangers of the Porro-Csesarean and Sanger-Csesarean methods, which 
have only within the years named ceased to be in some degree experi- 
mental. Old records are of historical interest and show the progressive 
steps by which the present low rate of death was reached. Even the 
miscalled " classic " operation can now be performed with much less 
risk ; but no wise man will trust the uterine wound to nature's closing 
when multiple suturing is so much more to be relied on. What is still 
to be learned, particularly in the United States and Great Britain, is the 
great value of elective, early, and time-chosen operations. — Ed.] That 
it is necessarily hopeless is certainly not the case, and we know that on 
the Continent, where it is resorted to much oftener and earlier in labor 
than in Great Britain, there are authentic cases in which it has been 
performed twice, thrice, and even, in one instance, four times, on the 
same patient. Keyser thinks that a second operation on the same 
patient aflPords a better prognosis than a first, probably because peri- 
toneal adhesions resulting from the first operation have shut off the 
general abdominal cavity from the uterine wound ; and he believes 
that in second operations the mortality is not more than 29 per cent. 

\} Observations on the C(jesarean Section and Craniotomy, by Thomas Kadford, M. D., 
London, 1880.— Ed.] 



THE CjESAREAN SECTION. 521 

The Csesarean Section in America. — The Caesarean section has 
been much more successful in America than in Great Britain. Dr. 
Harris of Philadelphia, who has paid much attention to the subject, 
has collected 184 cases occurring in the United States, of which 70, or 
about 38 per cent., were successful as regards the mother. These 
[relatively] favorable results he refers partly to the fact that none of 
the American cases were the subjects of mollities ossium, rachitic 
patients forming one-half of the entire number, partly to the preva- 
lence of habits of beer and gin-drinking in Great Britain. He also 
gives some interesting facts showing how remarkably the mortality of 
the operation is lessened when it is performed soon and the patient is 
not exhausted by long and fruitless labor. Out of 28 selected cases 
»of this kind, 21, or 75 per cent., were successful. [23 children Avere 
delivered alive, and 19 were saved. — Ed.] The latest European sta- 
tistics show that the modifications of the operation now universally 
adopted upon the continent of Europe are followed by the most grati- 
fying results. Thus, out of 22 recent operations 18 mothers recovered. 
Results to the Child. — The mortality of the children likewise can- 
not be ascertained from statistical returns, since in the large majority of 
cases in which dead children were extracted the result had nothing to 
do with the operation. Indeed, there is nothing in the operation itself 
which can reasonably be supposed to affect the child. If, therefore, the 
child be alive when the operation is commenced, there is every proba- 
bility of its being extracted alive ; and Radford's conclusion, that " the 
risk to infants in Csesarean births is not much greater than that w^hich 
is contingent on natural labor, provided correct principles of practice 
are adopted," probably very nearly represents the truth. [The records 
of elective operations show a mere fraction of foetal deaths. — Ed.] 

Causes Requiring- the Operation. — The Csesarean section is required 
when there is such defective proportion between the child and the mater- 
nal passages that even a mutilated foetus cannot be extracted. This in 
by far the greatest number of cases is due to deformity of tlie pelvis 
arising from rickets or mollities ossium. The latter may occur in a 
patient who has been previously healthy and Avho has given birth to 
living children. It is a more common cause of the extreme varieties 
of deformity than rickets ; and out of 132 British cases tabulated by 
Radford, P] in 56 the deformity was produced by osteomalacia and in 
31 by rickets. In certain cases the pelvis itself may be of normal size, 
but has its cavity obstructwl by a solid tumor of the ovary, of the uterus 
itself, or one growing from the pelvic wall. The obstruction may also 
depend on morbid conditions of the maternal soft parts, of which the 
most common is advanced malignant disease of the cervix. Other con- 
ditions may, however, render the operation essential. Thus, Dr. New- 
man^ records a case in which he ])er(brmed it for insurmountable resist- 
ance and obstruction of the cervix which was believed at that time to 
be caused by malignant disease. The patient recovered, and was subse- 
quently delivered naturally and without anything abnormal being made 
out. This renders it })robable that the disease was not malignant, and 
it may possibly have been an extensive inflanunatory exudation into the 

[1 Ediiiou of 1880.— El).] =» 06^•^ 7V(njs.. ISGG, vol. vii. p. 343. 



522 OBSTETRIC OPERATIONS. 

tissues of the cervix subsequently absorbed. I myself was present at a 
Ca^sarean section performed in Calcutta in the year 1857, when the pelvis 
Avas so uniformly blocked up with exudation, pi'obably due to extensive 
pelvic cellulitis or hsematocele, that the operation was essential. 

Limits of Obstruction Justifying" the Operation. — Different 
accoucheurs have fixed on various limits for the operation. Most 
British authorities are of opinion that it need not be resorted to if the 
smallest diameter of the pelvis exceed IJ inches.^ This question has 
already been considered in discussing craniotomy, and it has been shown 
that a mutilated foetus may be drawn through a pelvis of IJ inches 
antero-posterior diameter, provided there be a space of 3 inches in the 
transverse diameter. If sufficient space for using the necessary instru- 
ments do not exist, the Csesarean section may be required, even when 
there is a larger antero-posterior diameter than IJ inches. This is 
especially likely to occur Avhen we have to do with deformity arising 
from mollities ossium, in which the obstruction is in the sides and out- 
let of the pelvis, the true conjugate being sometimes even elongated. 
On the Continent the Csesarean section is constantly practised as an ope- 
ration of election when the smallest diameter measures from 2 to 2^ 
inches ; and when the child is known to be alive some foreign authors 
recommend it when there is as much as 3 inches in the antero-posterior 
diameter. In Great Britain, where the life of the child is most prop- 
erly considered of secondary importance to the safety of the mother, we 
cannot fix one limit for the operation when the child is living and 
another when it is dead. Xor, I think, can we admit the desire of the 
mother to run the risk, rather than sacrifice the child, as a justification 
of the operation, although this is laid down as an indication by Schroe- 
der.^ Great as are the dangers attending craniotomy in extreme deform- 
ity, there can be no doubt that we must perform it whenever it is prac- 
ticable, and only resort to the Csesarean section when no other means 
of delivery are possible. 

[One of the vital questions of the day is, ^' Shall the Csesarean ope- 
ration be performed in cases under relative indications f^^ That is. Is it 
proper to elect to perform the operation where the indications for it are 
not absolute and positive ? If by foetal destruction the mother can in 
all probability be saved, is it a justifiable act to run a greater risk in 
order to save the child ? Are the wishes of the parents for a living 
child to be considered in deciding as to the method of delivery? In 
view of the fact that a premature delivery cannot save the child in a 
given case, and the mother has already lost one or more foetuses by cra- 
niotomy, is it proper to save the child by an operation in which one out 
of five or six women have died ? We think it is, and for the reason 
that such cases generally have a less mortality than the average here 
given. — Ed.] 

For this reason I think it unnecessary to discuss the question whether 
we are justified in destroying the foetus in several successive pregnan- 
cies when the mother knows that it is impossible for her to give birth 

^ In Dr. Parry's table of 70 craniotomies there are 34 cases of 2 to 2^ inches con- 
jugate. 

2 Manual of Midwifery, p. 202. 



THE CJESAREAN SECTION. 523 

to a living child. Denman was the first to question the advisability of 
repeating craniotomy on the same patient. .Vmongst modern authors 
Radford takes the most decided view on this point, and distinctly teaches 
that even when delivery by craniotomy is possible it '^can be justified 
on no principle, and is only sanctioned by the dogma of the schools or 
by usage/^ and that therefore the Csesarean section should be performed 
with the view of saving the child. Doubtless much can be said from 
this point of view ; but nevertheless he would be a bold man who would 
deliberately elect to perform the Csesarean section on such grounds.^ It 
is to be hoped, however, that in these days the induction of premature 
labor or abortion would always spare us the necessity of deciding so 
delicate a point. 

Post-mortem Caesarean Operation. — The C^esarean section may 
also be required in cases in which death has occurred during pregnancy 
or labor. This was the indication for which it was first employed, and 
it has constantly been performed when a pregnant woman has died at 
an advanced period of utero-gestation. There is no doubt that a prompt 
extraction of the child under these circumstances has frequently been the 
means of saving its life, but by no means so often as is generally sup- 
posed. Thus, Schwarz ^ showed that out of 107 cases not one living 
child was extracted. Duer^ has written an interesting paper on this 
subject, in Avhich he has tabulated 55 cases of post-mortem C?esarean 
sections. In 40 a living child was extracted, the time elapsing after 
the death of the mother being as follows : " Between one and five 
minutes, including ^ immediately ' and ' in a few minutes,' there were 21 
cases ; between five and ten minutes, none ; between ten and fifteen 
minutes, 13 cases; between fifteen and twenty-three minutes, 2 cases; 
after one hour, 2 cases ; and after two hours, 2 cases.'' In those 
extracted, however, after the lapse of an hour the children did not ulti- 
mately survive, and the cases themselves seem open to some doubt. 

Want of Success in Post-mortem Operation. — The reason that 
the want of success has been so great is doubtless the delay that must 
necessarily occur before the operation is resorted to, for, independently 
of the fact that the practitioner is seldom at hand at the moment of 
death, the very time necessary to assure ourselves that life is actually 
extin(!t will genei-ally be sufficient to cause the death of the fc^tus. 
Considering the intimate relations between the mother and child, we 
can scarcely expect vitality to remain in the latter more than a quarter, 
or, at the outside, half, an hour after it has ceased in the former. The 
recorded instances in which a living child was extracted ten, twelve, and 
even forty hours after death were most probably cases in which the 
mother fell into a prolonged trance or swoon, during the contiuuance o( 
which the child nuist have been removed. A lew authentic lases, how- 

^ This was (Unie twice siu'cessfiiUy by Prof. ^Villi;un viibson in iho case ot' Mfs. Kov- 
bold of IMiiladolphia, in 18I>'") and 1S;>7, altor she luul twice been delivered by cranioi- 
oniy nnder Prof. Charles I). ]\Iei.s;s, who declineil destroyinjx any nunv children for 
her. ]\Irs. U, still lives at tlie age of v^eventy, ami the danuhter and son likewise, with 
their six children. — Harris' note to od American edition. [She diinl .Vug. 15, ISSo, 
aged 7(). — Kd.] 
'2 Mount, f. Gi'bio't. snppl. 1S()*2. Hd. xviii. S. IPJ. 

^ " Post-mortem Delivery," Amcr. Joitrn. of Obst., 1870, vol. xii. \^[*. I and Mi. 



524 OBSTETRIC OPERATIONS. 

ever, are known in which there can be no reasonable doubt that the 
operation was performed successfully several hours after the mother Avas 
actually dead. 

Since^ then, there is a chance, however slight, of saving the child's 
life, we are bound to perform the operation, even when so much time 
has elapsed as to render the chances of success extremely small. It 
might be considered almost superfluous to insist on the necessity of 
assuring ourselves of the mother's death before commencing the neces- 
sary incisions; but, unfortunately, numerous instances are known in 
which mistakes in diagnosis have been made, and in w^iich the first 
steps of the operation have shown that the mother w^as still alive. The 
operation should therefore always be performed with the same care and 
caution as if the mother were living. If death have occurred during 
labor, some have advised version as a preferable alternative. This can 
only be resorted to with any hope of success if the passages be in a con- 
dition to admit of delivery with rapidity ; otherwise the delay occa- 
sioned by dilatation, even when forcibly accomplished, and the drawing 
of the child through the pelvis, will be almost necessarily fatal. The 
only argument in favor of version is that it is less painful to the friends; 
and if they manifest a decided objection to the Csesarean section, there 
can be no reason why an attempt to save the child in this way should 
not be made. 

Causes of Death after Csesarean Section. — The causes of death 
after the Csesarean section may, speaking generally, be classed under 
four principal heads: hemorrhage, peritonitis and metritis, shock, septi- 
caemia and exhaustion from long delay. These are pretty much the 
same as those following ovariotomy, and the resemblance between the 
two operations is so great that modern experience as to the best mode 
of performing ovariotomy, as well as regards the after-treatment, may 
be taken as a guide in the management of cases of Csesarean section. 

Hemorrhage to an alarming extent is a frequent complication, though 
seldom the cause of death. Thus, out of 88 operations, the particulars 
of which have been carefully noted, severe hemorrhage occurred in 14, 
6 of which terminated successfully, and in 4 only could the fatal result 
be ascribed to the loss of blood. In 1 of these the source of the hem- 
orrhage is not mentioned, in another it came from the w^ound in the 
abdominal wall, and in the other 2 from the uterine incision being made 
directly over the placenta. In neither of the two latter was the loss of 
blood immediately fatal, for it was checked by uterine contraction, and 
only recurred after many hours had elapsed. The divided uterine 
sinuses, and the open mouths of the vessels at the placental site are the 
most common sources of hemorrhage. 

Much may be done to diminish the risk of bleeding, but even w^ith 
every precaution it must be a source of danger. Hemorrhage from the 
abdominal wall may be best prevented by making the incision as nearly 
as possible in the line of the linea alba, so as not to wound the epigas- 
tric arteries, and by controlling bleeding by pressure-forceps as we pro- 
ceed, as is done in ovariotomy. The principal loss of blood will be met 
with in dividing the uterus, and this will be the greatest when the incis- 
ion is near or over the placental site, where the largest vessels are met 



THE CJESAIiEAN SECTION. 525 

with. We are recommended to ascertain the position of the placenta 
by auscultation, and thus, if possible, to avoid opening the uterus near 
its insertion. JBut even if we admit the placental souffle to be a guide 
to its situation if the placenta be attached to the anterior walls of the 
uterus, a knowledge of its position would not always enable us to avoid 
opening the uterus in its immediate vicinity. We. must, in the event 
of its lying under the incision, rather hope to control the hemorrhage 
by removing it at once from its attachments and rapidly emptying the 
uterus. When the child has been removed there may be a large escape 
of blood, but this will generally be stopped by the contraction of the 
uterus in the same manner as after natural labor. Should contraction 
not take place, the uterus may be firmly grasped for the purpose of 
exciting it. This plan is advocated by Ludwig Winckel, who had a 
large experience in the operation, and by using free compression in this 
way, and making a point of not closing the wound until the uterus is 
firmly contracted, he has never met with any inconvenience from hem- 
orrhage. If bleeding continue, styptic applications may be used, as in 
a case reported by Hicks, who was obliged to swab out the uterine cav- 
ity with a solution of perchloride of iron. The method first used by [^] 
Mliller, and now adopted by most operators, of placing a soft-rubber 
cord round the uterus after its contents have been removed, will tend 
effectually to control hemorrhage, and should always be employed. [It 
is often applied before the uterine incision is made. — Ed.] 

Among the most frequent causes of death are peritonitis and metritis, 
Kayser attributes the fatal results to them in 77 out 123 unsuccessful 
cases. [Of 79 deaths specially noted in this country, 31 were from 
peritonitis, 17 from exhaustion, 14 from septicaemia, 12 from shock, 
and 5 from internal hemorrhage. — Ed.] 

The mere division of the peritoneum will not account for the fre- 
quency of this complication, since its occurrence is considerably more 
frequent than after ovariotomy, in which the injury to the peritoneum 
is quite as great, and indeed greater if we take into account the adhe- 
sions which have to be divided or torn in that operation. 

The division of the uterus must be regarded as one source of this 
danger. Dr. West lays great stress on its unfavorable condition after 
delivery for reparative action. He believes that the process of involu- 
tion or fatty degeneration which commences in the nuiscular fibres pre- 
vious to delivery renders them peculiarly unfitted to cicatrize ; and ho 
])oints out that on post-mortem examination the edges of the incision 
have been found dry, of unhealthy color, gaping, and showing no tend- 
ency to heal. On this account Hicks and others have operated ten days 
or more before the full period of labor, in the hope that the risk from 
this source might be avoided. [Recent careful investigations have pro\ (h1 
this to be a fallacy. There is nothing in the post-partum uterine 
changes to interfere with the ])roc'ess of healing if the tis.^ues of the 
organ are in a normal state. An operation before labor or just alter it 
has begun will be followed usually by a raf)id tMcatrization if the woman 
is in fair health. — Ed.] 'It is by no means certain, liowever, that the 
change in the uterine fibres is the cause of the wound not healing, and 

{} It wiis by Prof. Litzmann of Kiel, in 1878. — Ki\] 



526 OBSTETRIC OPERATIONS. 

involution will commence at once when the uterus is emptied, even if 
the full period of pregnancy have not arrived. As a point of ethics, 
moreover, it is questionable if Ave are justified in anticipating the date 
of so dangerous an operation, even by a few weeks, unless the benefit to 
be derived is very decided indeed. [The teaching of Profs. Goodell, 
Lusk, and Kelly, all successful oj^erators, haviug saved seven cases collec- 
tively, is not in correspondence with this opinion. Having far less fear 
of the operation than Prof. Playfair lias, our best operators prefer in 
many cases to make the section before labor has commenced, so as to 
select an opportune time and secure the best possible results. — Ed.] 

One important cause of peritonitis is the escape of the lochia through 
the uterine incision into the cavity of the peritoneum, which there 
decompose and act as an unfailing source of irritation. This may be 
prevented, to a great extent, by seeing that the os uteri is patulous, so 
as to afford a channel for the escape of discharges and by effective 
closing of the uterine wouud by sutures. In addition, there is the 
danger arising from blood and liquor amnii escaping into the peritoneum, 
and subsequently decomposing. There is little evidence that " la toilette 
du peritoine,'' on which ovariotomists now lay so much stress, has ever 
been particularly attended to in C?esarean operations. [^] 

The chief predisposing cause of these inflammations, however, must 
be looked for in the condition of the patient, just as asthenic inflamma- 
tion in ovariotomy is most frequently met with in those whose general 
health is broken down by the long continuance of the disease. We are 
fully justified, therefore, in assuming that peritonitis and metritis will 
be more likely to occur after the Csesarean section when that operation 
has been unnecessarily delayed and when the patient is exhausted by a 
protracted labor. In proof of this we find that in a large proportion 
of the cases, above mentioned peritonitis occurred when the operation 
was performed under unfavorable conditions. 

The sources of septicsemia are abundantly evident, not the least, 
probably, being absorption by the open vessels in the uterine incision. 

The last great danger is general shock to the nervous system. In 
Ivayser's 123 cases, 30 of the deaths- are referred to this cause. In the 
large majority of these the patient was profoundly exhausted before 
the operation was begun. It is in predisposing to these nervous com- 
plications that we should, a jyriori, expect that vacillation and delay 
would be most hurtful ; and in operating when the patient's strength is 
still unimpaired we afford her the best chance of bearing the inevitable 
shock of an operation of such magnitude. 

In addition, a few cases have been lost from accidental complications, 
which are liable to occur after any serious operation, and which do not 
necessarily depend on the nature of the procedure. 

There is only one source of danger special to the child which is 
worthy of attention. As the infant is being removed from the cavity 
of the uterus the muscular parietes sometimes contract with great rapidity 
and force, so as to seize and retain some part of its body. This occurred 
in two of Dr. Radford's cases, and in one of them it is stated that " the 

[^ This certainly does not apply to many recent opei-ations in our country and upon 
the continent of Europe. — Ed.] 



THE CJESAREAN SECTION. 527 

child was vigorously alive when first taken liold of, l)ut from the length of 
time occupied in extracting the head it became so enfeebled as to show 
only slight signs of life/^ and subsequently all attempts at resuscitation 
failed. I have myself seen the head caught in this way, and so f^jrcibly 
retained that a second incision was required to release it. In Dr. Rad- 
ford's cases the placenta happened to be immediately under the incision, 
and he attributes the inordinate and rapid contraction of the uterus to 
its premature separation. It is difficult to believe that this was more 
than a coincidence, because the contraction does not take place until the 
greater part of the child's body has been withdrawn, and because numer- 
ous cases are recorded in which the uterus was opened directly over the 
placenta or in which it was lying loose and detached, in none of which 
this accident occurred. The true explanation may, I think, be found 
in the varying irritability of the uterus in different cases. 

Irrespective of the risk of portions of the child being caught and 
detained, rapid contraction is a distinct advantage, since the danger of 
hemorrhage is thereby thus diminished. Serious consequences may be 
best avoided by removing, when practicable, the head and shoulders of 
the child first, or by employing both hands in extraction, one being 
placed near the head, the other seizing the feet. Either of these 
methods is preferable to the common practice of laying hold of the 
part that may chance to lie most conveniently near the line of incision. 
If this point were properly attended to, although the detention of the 
lower extremities might occasionally occur, the life of the child w^ould 
not be imperilled. [We teach just the reverse in this country, and 
.that is to deliver by the feet; which is also in accordance with the 
directions given in continental Europe. A rapid pedal delivery runs 
no risk of the foetus being caught by the neck. — Ed.] 

The Patient should be Prepared for the Operation. — The prep- 
aration of the patient for the operation should seriously occupy the 
attention of the practitioner, and this is the more essential since almost 
all patients requiring the Csesarean section are in a wretchedly debili- 
tated condition. If the patient be not seen until she is actually in 
labor, of course this is out of the question. But this will rarely be the 
case, since the deformed condition of the patient nuist generally have 
attracted attention. Every possible means should be taken, therefore, 
when practicable, to improve the general health by abundance of simple 
and nourishing diet, plenty of fresh air, and suitable tonics (amongst 
whicli preparations of iron should 0('cu})y a })rominent place), while the 
state of the secretions, the bowels, skin, and kidneys should be specially 
attended to. Whenever it is possibU> a large, airy a[)artment should be 
sele(;ted for the o})eration, which should never be done in a hospital if 
other arrangements be practicable. [^] These details may seem trivial and 
unnecessary, but to ensure success in so hazardous an undertaking no 
care can be considered suporliuous, and probably the want of attention 
to such points has had much to do with increasing the mortalitv. 

Th(» (piestion arises whether we slu>iild ojHM-ate before labor has com- 
menced. By selecting^ our mvn time, as sonu> have advised, wo cortaiidv 

\} In this oountrv wo beliovo now that oasos do bettor in hospital, as a goiioral ruio. 
than at their own homes. — Ki\] 



528 OBSTETRIC OPERATIONS. 

have the advantage of operating under the most favorable conditions 
instead of possibly hurriedly. There are, however, numerous advan- 
tages in waiting until spontaneous uterine action has commenced which 
seem to me to more than counterbalance the advantages of choosing our 
own time. Prominent among these is the partial opening of the os 
uteri, so as to afford a channel for the escape of the lochia, and the cer- 
tainty of active contraction of the uterus to arrest hemorrhage. Barnes 
recommends that premature labor should be first induced, and then the 
operation performed. This seems to me to introduce a needless element 
of complexity ; and besides, in cases of great deformity it is by no 
means always easy to reach the cervix with the view of bringing on 
labor. All needful arrangements should be made, so as to avoid hurry 
and excitement when the operation is commenced, and we may then 
wait patiently until labor has fairly set in. [I have seen operations 
performed before labor began, soon after labor w^as induced, and after 
it came on naturally, and confess that I prefer the advantages afforded 
by the first. Unless there is stenosis of the cervix it will generally be 
wide enough open for drainage ; if it is not, labor can be safely induced 
at a selected time. — Ed.] 

The Administration of Anaesthetics. — The operation itself is sim- 
ple. The patient should be placed on a table in a good light and with 
the temperature of the room raised to about 65°. Chloroform has so 
frequently been followed by severe vomiting that it is probably better 
not to administer it. For the same reason, Mr. Spencer Wells has long 
given up using it in ovariotomy, and finds that chloro-methyl answers 
admirably; ether also is devoid of the disadvantages of chloroform. Iru 
one or two cases local ansesthesia has been used by means of two spray- 
producers acting simultaneously ; and this plan, if the patient have suf- 
ficient fortitude to dispense with general ansesthesia, has the further 
advantage of stimulating the uterus to powerful contraction. 

To ensure as great a measure of success as possible the operation 
should be performed with all the minute precautions used in ovari- 
otomy. 

Description of the Operation. — The incision should be made as 
much as possible in the line of the linea alba, so as to avoid wounding 
the epigastric arteries. On account of the deformity the configuration 
of the abdomen is often much altered, and some have advised that the 
incision should be made oblique or transverse and on the most promi- 
nent part of the abdomen. The risk of hemorrhage being thus much 
increased, the practice is not to be recommended. [The color-line so 
common in pregnancy will indicate in many women the direction the 
incision is to take in order to strike the linea alba correctly. The more 
truly this is done, the less likely is hemorrhage to occur from the edges 
of the wound. — Ed.] The incision, commencing a little above the 
umbilicus, is carried down for about three inches below it. The skin 
and muscular fibres are carefully divided, layer by layer, until the shin- 
ing surface of the peritoneum is reached, and any bleeding vessels 
should be secured as we proceed. A small opening is now made in the 
peritoneum, which should be laid open along the whole length of the 
incision upon two fingers of the left hand introduced as a guide. A 



THE CJESAREAN SECTION. o29 

few silk sutures, three or four, should now be passed through the upper 
end of the incision. The obje(;t of these is to temporarily close the 
abdominal parietes after the uterus is opened, so as to prevent the escape 
of the intestines, or the entrance of blood, etc. into the peritoneal cavity. 
Before incising the uterus an assistant should carefully support it in a 
proper position, and push it forward by the hands placed on either side 
of the incision, so as to bring its surface into apposition with the exter- 
nal wound and ])revent the escape of the intestines. If we have 
reason to believe that the placenta is situated anteriorly, we may incise 
the uterus on one or other side ; otherwise the line of incision should 
be as nearly as possible central. The substance of the uterus is next 
divided until the membranes are reached, which are punctured and 
divided in the same way as the peritoneum. The uterine incision should 
be of the same length as that in the abdomen, and it should not be made 
too near the fundus, for not only is that part more vascular than the 
body of the uterus, but wounds in that situation are more apt to gape, 
and do not cicatrize so favorably. After the uterus is opened Dr. Lud- 
wig Winckel recommends that the fingers of an assistant should be 
placed in the two terminal angles of the wound, so that the ends of the 
incision may be hooked up and brought into close apposition with the 
abdominal opening. By this means he prevents not only the escape of 
blood and liquor amnii into the cavity of the peritoneum, but also the 
protrusion of the abdominal viscera. 

Removal of the Child. — The child should now be carefully removed, 
the head and shoulders being taken out (if possible) first ; [^] the placenta 
and membranes are afterward extracted. Should the placenta be unfor- 
tunately found immediately under the incision, a considerable loss of 
blood is likely to take place, which can only be checked by removing 
it from its attachments and concluding the operation as rapidly as pos- 
sible. 

Eventration of the Uterus. — As soon as the child is removed the 
uterus should be turned out of the abdominal cavity, which is tenijio- 
rarily closed by the sutures already introduced, and further protected by 
placing a large flat sponge behind the uterus. At the same time, hem- 
orrhage is controlled by a rubber cord tied round the cervix. [In 
many cases the uterus is turned out whole, the cervix is constricted by 
manual pressure or the tube of Esmarch, and then the uterus is opened 
and the foetus removed. In such operations the fivtus is usually some- 
what asphyxiated. — Ed.] Tliis gives time thoroughly to attend to the 
suturing of the uterine incision, a point of groat importance. The 
uterus should now be surrounded by soft napkins wrung out ot" warm 
l-in-2000 perchloride-of-mercury solution. After the placenta has been 
removed and the hemorrhage arrested we should see that the os uteri is 
open, so that any fluid in the uterine cavity may drain into the vagina. 
The cavity should also be dusted with iodoform. 

Importance of Securing- Uterine Contraction. — As soon as the 
child and the secundines have been extracted, the sooner the uterus eon- 
tracts the better. It will' usually do so of itself, but should it remain 

[^ We say hero, loot tirst, aooonlinu' to tho most oxporionood oontinontal authori- 
ties.— Ed.] 



530 OBSTETRIC OPERATIONS. 

lax and flabby it should be pressed and stimulated by the hand. We 
are specially warned against handling the uterus by Ramsbotham and 
others ; but there seems no valid reason why we should not restrain 
hemorrliage in this way as after a natural labor. The intervention of 
the abdominal parietes in their lax condition after delivery can make 
very little difference between the two cases. Ergotine administered 
hypodermically will also be useful in promoting efficient contraction. 

Closure of the Uterine Wound. — Much of the recent success in 
this operation is due to the careful closing of the uterine incision by 
sutures. Sanger, who has paid great attention to this point, strips off 
the peritoneum for about five centimeters on eacli side of the incision, 
and then resects the muscular wall for about two centimeters. [^] [This 
is very rarely done now by any operator, unless the peritoneum is so 
tightly adherent that it will not slide over the muscular coat, which is 
seldom the case. — Ed.] This done, he inserts eight to ten deep sutures 
of soft silver wire through the peritoneum and muscle, but not through 
the mucosa, taking care to turn in the soft peritoneal flaps so as to bring 
them into accurate contact, with the view of securing rapid adhesion. 
The reason for not passing the suture into the uterine cavity is to pre- 
vent the possibility of septic material finding its way along the track 
of the sutures into the peritoneum. Finally, he passes twenty to twenty- 
five fine silk sutures through the inverted edges of the peritoneum. 
Leopold, wdio saved sixteen out of nineteen cases at Dresden, adopts 
much the same plan, but he does not strip off the peritoneal flaps nor 
excise any portion of the uterine walls ; and his method is certainly 
simpler and apparently quite as effectual. The provisional elastic tub- 
ing may now be removed and the uterus replaced in the abdominal 
cavity. 

[Pure Chinese silk is the material generally preferred for both 
the deep and superficial uterine sutures. The Lembert stitches are usu- 
ally a few more than the deep-seated: 10 or 12 deep, and 14 to 16 
Lembert, are about the average. Silver wire is still preferred by a few 
operators, and chromic catgut by others, for the deep sutures. Catgut 
is not a very safe material for holding its knots. — Ed.] 

A point of great importance, and not sufficiently insisted on, is the 
advisability of not closing the abdominal wound until we are thoroughly 
satisfied that hemorrhage is completely stopped, since any escape of 
blood into the peritoneum would very materially lessen the chances of 
recovery. In a successful case reported by Dr. NeVman^ the wound was 
not closed for nearly an hour. [Where the uterus is properly sutured 
there can be no occasion for this delay. The Esmarch tube prevents 
blood-loss while the uterine wound is being closed, and the suture-pres- 
sure prevents it after the tube is taken off. Under the old operation delay 
was valuable, but it is not required now. We have seen three successful 
operations entirely completed in thirty-five, thirty-two, and twenty- 
five minutes respectively. The great danger from hemorrhage is dur- 
ing the incising and evacuating of the uterus where the placenta is 

\} These measures are in error by an oversight. Five centimeters are nearly two 
inches, and two are f of an inch ; millimeters are intended. — Ed.] 
2 Ohst. Trans., 1867, vol. viii. p. 343. 



THE CESAREAN SECTION. 531 

under the line of incision. — Ed.] Before doing so all blood and dis- 
charges should be carefully nemoved from the peritoneal cavity by clean 
soft sponges dipped in warm water. The abdominal wound sliould be 
closed from above downward by wire or silk sutures, which shoidd be 
inserted at a distance of an inch from each other and passed entirely 
through the abdominal walls and the peritoneum, at some little distance 
from the edges of the incision, so as to bring the two surfaces of the 
peritoneum into contact. [^] By this means we ensure the closure of the 
peritoneal cavity, the opposed surfaces adhering with great rapidity. If, 
as should be the case, the operation is performed with full antiseptic pre- 
cautions, the wound should now be dressed precisely as after ovariotomy. 

Subsequent Manag-eraent. — Into the subsequent treatment it is 
unnecessary to enter at any length, since it must be regulated by gen- 
eral principles, each symptom being met as it arises. It has been cus- 
tomary to administer opiates freely after the operation, but they seem to 
have a tendency to produce sickness and vomiting, and ought not to be 
exhibited unless pain or peritonitis indicates that they are required. In 
fact, the treatment should in no way differ from that usual after ovari- 
otomy, and the principles that should guide us will be best shown by the 
following quotation from Mr. Spencer Wells' description of that opera- 
tion : '' The principles of after-treatment are — to obtain extreme quiet, 
comfortable warmth, and perfectly clean linen to the patient ; to relieve 
pain by warm applications to the abdomen and by opiate enemas ; to give 
stimulants when they are called for by failing pulse or other signs of 
exhaustion ; to relieve sickness by ice or iced drinks ; and to allow plain, 
simple, but nourishing food. The catheter must be used every six or 
eight hours, until the patient can move without pain. The sutures are 
removed on the third day, [^] unless tympanitic distension of the stomach 
or intestines endangers reopening of the Avound. In such circumstances 
they may be left for some days longer. The superficial sutures may 
remain until union seems quite firm.'' 

Porro's Operation. — Within the last few years an important mixii- 
fication of the Ciesarean section has been adopted, which is generally 
known as Porro's oi)eration, from Professor Porro of Pa via, who was 
the first European surgeon who practised it. In this operation, after 
the uterus is emptied the entire organ is drawn out of the abdominal 
wound and excised, its neck being first constricted so as to suj^press 
hemorrhage, the stump being fixed externally in the manner of the 
pedi(5le in ovariotomy. The idea is by no means new. It appears to 
have been first suggested by an Italian — Dr. Cavallini — in 1768. In 
1823 the late Dr. J^lundell made the same proposal, and fortifitnl it by 
numerous experiments on pregnant rabbits, in the course of which he 
found that he lost all by the (^jesarean section, but siivcnl three out of four 
in which lie ligaturinl and aniputntiHl the uterus. The suggestion was 
not, however, carried into actual practice until Dr. Storer i)f Boston in 
18()9 removed the uterus in a case o^ libroid tumor c4>structing the 
pelvis and impeding delivery. 

\} Ainoricnn (>|HM-:it(>rs profor to put ihoir sutures luuoh nonror tliau tlu> to diminisli 
the individual ttMision. — Kn.j 

[* JIarely bet'ore the sixth to oiuhlh in the Tnilod Stales. — Ki>.] 



532 OB.^IEIBIC OFEEAIIOy.S. 

Since Potto's first case the «:»peration has betn frequently performed 
on the Continent, with results which are. on the whole, encouraging. 
The cases have been carefully tabulated by Dr. Harris of Philadelphia, 
and more recently and very completely by Dr. Clement Godson,^ who 
has ct^llected 215- cas^. out of which 109. or 5C>.6 per cent., were suc- 
cesst'ol as regards the mother. [Dr. Godson is much l^ehind in his 
record, as my table has 260 cases up to the same date, ^-ith 142 women 
saved. There were 89 operations, with 19 deaths and 1 suicide, in the 
years 1885, 1886, 1887. and 1888. — Ed.] The obvious advantage of 
this plan is, that instead of leaving the incised uterus, with its proba- 
bly gaping woimd and all the attendant risk of septic mischief, in the 
aMominal cavity, it is fixed externally and in a position where it can \je 
readily dressed. 

The objection is that it entirely tmsexes the patient, but in the class 
of women requiring the Gaesarean section from pelvic deformity it is 
questionable whether this can be fairly c<Dnsidered as a drawback. It 
is perhaps not justiiiable to attempt as yet any pc«sitive decision as to 
the indications for this plan. It certainly seemed at first to be less 
dangerotis than the Ctesarean section, but the improved results recently 
obtaiued in the latter operation have shown how it afibrds the patient 
as good if not a better chance, without p>ermanent mutilation. ** It 
seems probable, therefore, that in future the Porro operation ^viU be 
chiefly adopted when for some reason, such as the existence of fibro- 
myomata. the ablation of the uterus is specially indictited." [We 
bebeve that the Porro operation will, in all prohiability. meet with 
better success than the ** ci:»nservative *■ method in Great Britain, from 
the fact that the last five cases in order have all recovered. Holding 
the \-iews there generally advocated, the section will only be made ia 
badly-deformed rachitic dwarts and in the subjects of malacosteon, 
which are much more frequently thus delivered than the former. 
These will probably do bener under the exsective method, which 
brides has the advantage that it sometimes cures malacosteon. as shown 
bv the results in continental Europe. — Ed.] The operation in the sue- 
cesslul cases has l>een performed with full antiseptic precautions, and 
the neck of the utems. after the organ is emptied, carelully sectired by 
ligatures before its Kxly is amputated. Some operators have encircled 
the neck of the uterus with a chain or wire ecrasetir before removing 
it, and by this means completely controlled hemorrhage. Richardson ^ 
transfixed the neck of the uterus with two large pins crossing each 
other before removing the wire of the ecraseur, and encircled it with 
stout carbolized cc»rd. Muller of Berne has recommended that the entire 
uterus should be turned out of the abdominal c-tvity through a long 
incision Ix-fore it is emptied, so as to avoid the risk of its fluid contents 
entering the aMomen ; but this manoeuvre has not always proved feasi- 
ble. The pedicle has generally been fixed in the lower angle of the 
abdominal wound and dressed antiseptic-ally. In most cases one or 

' "Porro's Operation," BriL Med. Joum.. 1^S4. vol. i p. 142. 

* Dr. Godstm has hindlr made np these figures f:r rce np to the preseni date Jann- 
aiy, 1889*. 

* Amerwun Journ, cf JLid. .ViVncf. 18S1. 



THE CESAREAN SECTION. 533 

more drainage-tubes liave been used, either through Douglas' space or 
in the abdominal wound. 

Symphysiotomy. — Bearing in mind the great mortality attending 
the Csesarean section, it is not surprising that obstetricians should have 
anxiously considered the possibility of devising a substitute which 
should afford the mother a better chance of recovery. The first pro- 
posal of the kind was one from which great results were at first antici- 
pated. In 1768, Sigault, then a student of medicine at Angers, sug- 
gested symphysiotomy, which consists in the division of the symphysis 
pubis with a view of allowing the pubic bones to separate sufficiently 
to admit of the passage of the child. [The idea was not original, 
but came from reading the work of Severin Pineau, who suggested 
it. — Ed.] Although at first strongly opposed, it was subsequently 
ardently advocated by many obstetricians, and was often performed on 
the Continent and in a few cases in England. [^] 

It is generally admitted that it is quite impossible to make this a substi- 
tute for the Csesarean section, since the utmost gain which a wide sep- 
aration of the symphysis pubis would give would be altogether insuffi- 
cient to admit of the passage of even a mutilated foetus. Dr. Churchill 
concludes tliat if it were possible to separate it to the extent of four 
inches, we should only have an increase of from four lines to half an 
inch in the antero-posterior diameter, in Avhich the obstruction is gen- 
erally most marked. In the lesser degrees of deformity this might 
possibly be sufficient to allow the foetus to pass, but the risk of the 
operation itself, and the subsequent ill effects, P] altogether contra- 
indicate it in cases of this description. 

[As the Neapolitan advocates of symphysiotomy do not advise its 
performance in cases with a conjugate of less measure than 67 milli- 
meters, or 2| inches, it is not adapted to extreme pelvic deformities, 
and cannot take the place of the Csesarean section. The design of the 
operation is to avoid craniotomy in cases where the forceps cannot be 
made effective, and where a moderate increase of pelvic space will 
enable a mother to deliver herself of a living foetus. The first 50 
operations after the revival in Naples in 1866 saved 40 women and 
41 children. — Ed.] 

f ' Once only by Mr, Jolin Welcliman of Kinj^ston, Eno:., in 17S2. — En.] 

[^]*rof. Ottavio Morisani of Naples, the best livinj; authority, denies the existence 

of the "subsequent" ill efiects claimed by Robert Rarnes and others in England, 

Women have been twice operated upon with success. — Ed.] 



534 OBSTETRIC OPERATIONS. 



CHAPTER VII. 

LAPAEO-ELYTHOTOMY. 

Ix the early editioDS of this T\ork laparo-elytrotomy was briefly 
coDsidered as one of the suggested substitutes for tlie Caesarean section 
which merited careful study and appeared to be of a promising charac- 
ter, but of which too little was known to justify any positive conclu- 
sions with regard to it. The subject naturally attracted considerable 
attention, and several interesting papers have appeared in which its 
indications, difficulties, and advantages have been carefully considered. 
Since Thomas' first case was published several operations have been 
performed, with results so encouraging that I cannot but believe that 
the operation has a future before it, and that it may sometimes be 
resorted to instead of the more hazardous Caesarean section unless some 
special contraindication exists. Under these circumstances it seems 
proper no longer to consider it as an addendum to the description of 
the Csesarean section, but to study it more in detail in a separate 
chapter. 

History. — The history of the operation is ciu'ious and interesting. 
The earliest suggestion of a procedure of this character seems to have 
been made by Joerg in the year 1806, who proposed a modified Caesa- 
rean section, without incision of the uterus, by the division of the linea 
alba and of the uj^per part of the vagina, the foetus being extracted 
through the cervix. This suggestion was never carried into practice, 
and it is obvious that it misses the one chief advantage of laparo- 
elytrotomy, the leaving of the peritoneum intact. In 1820, Eitgen 
proposed and actually attempted an operation much resembling 
Thomas', in which section of the peritoneum was avoided. He 
failed, however, to complete it, and was eventually compelled to 
deliver his patient by the Caesarean section. In 1823, Baudelocque 
the younger independently conceived the same idea, and actually car- 
ried it into practice, although withotit success. Lastly, in 1837, Sir 
Charles Bell suggested a similar operation, clearly perceiving its advan- 
tages. Hence it appears that previous to Thomas' recent work in the 
matter the operation was independently invented no less than three times. 
It fell, however, entirely into oblivion, and was only occasionally men- 
tioned in systematic works as a matter of curious obstetric history, no 
one apparently appreciating the promising character of the procedure. 

In the year 1870, Dr. T. Gaillard Thomas of Xew York read a 
paper before the Medical Association of the town of Yonkers on the 
Hudson River entitled " Gastro-elytrotomy a Substitute for the Cae.sa- 
rean Section," in Avhich he described the operation as he had performed 
it three times on the dead subject, and once on a married woman in 1870, 
with a successful issue as regards the child. It seems beyond doubt that 



LAPARO-EL YTROTOMY. 535 

Thomas invented the operation for himself, being ignorant of Ritgen's 
and Baudelocque's previous attempts, and it is certain, to quote Gar- 
rigues,^ that to him " belongs the glory of having been the first who 
performed gastro-elytrotomy soas to extract a living child from a living 
mother in his first operation, and of haviug brought both mother and 
child to complete recovery in his second operation." 

Since Thomas' first case the operation has been performed four times 
by Dr. Skene of Brooklyn, and has found its way across the Atlantic, 
having been performed by Hime in Sheffield, Edis in London, and 
Foul let in Lyons. 

[Laparo-elytrotomy has been performed 14 times with 7 recoveries : 
5 children were dead ; 1 died in an hour ; 1 died in eighteen days, and 7 
are recorded as ^^ saved." In successful issue it is now much behind the 
average of the Sanger and Porro operations of the last four years. — Ed.] 

Nature of the Operation. — The object of laparo-elytrotomy is to 
reach the cervix by incision through the lower part of the abdominal 
wall and upper part of the vagina, and through it to extract the foetus 
as may most easily be done. 

Advantag-es over the Csesarean Section. — If this procedure is 
found practicable, the enormous advantages it offers over the Ciesareaa 
section are at once apparent, since in dividing the abdomen the ab- 
dominal wall only is incised and the peritoneum is left intact. The 
vagina is divided, but incision of the uterine parietes, which forms 
one of the chief risks of the C^esarean section, is entirely avoided. Xow 
there is nothing in either of these procedures alarming in itself, and if 
further experience proves that the practical difficulties of the operation 
do not stand in the way of its adoption. Dr. Thomas will have intro- 
duced by his able advocacy of the operation probably the greatest 
improvement in modern obstetrics. 

Cases Suitable for the Operation. — It may be broadly stated that 
laparo-elytrotomy is applicable in all cases calling for the Ciesarean sec- 
tion when the mother is alive. In post-mortem extractions of the fetus 
the CiGsarean section, being the most rapid procedure, would certainly 
be preferable. Exceptions must be made for certain cases of morbid 
conditions of the soft parts which render delivery per vias nafu rales 
impossible, and in which laparo-elytrotomy could not be performed, as 
in cases of tumor obstructing the })elvic cavit}', also in carcinoma or 
fibroid of the uterus. When the head is firndy impacted in the pelvic 
brim and cannot bo dislodged, the operation would be impossible, as the 
vagina could not be incised. [In more than 25 j>er cent, of American 
Cjiesareau cases laparo-elytrotomy was cciicn'n/i/ inapjilicable. It was 
prohahlj/ so in a number more, perhaps in all nearly one-third. — 1m\] 
Uidike the C^jcsarean section, tlu* operation cannot be pert'ornuHl twicv 
on the same patient, at least on the .same side, since adhesions lett by 
the former incisions would prevent the separatiiMi ot' the peritiMunuu 
and division of the vagina. It remains i(^ he sccmi whether in rcnaiii 
cases of extreme defor^nity, with pendulous abdomen and distiM'ttxi 
thighs, the site of incision might not be so iliilicult to reach as to ren- 
der the nec(ssarv manonivres imp(>ssibK\ 

' Xcir York Mai. JoKni., ISTv^, vol. xxviii. pp. ;v>7. ■t4i>. 



536 OBSTETRIC OPERATIOyS. 

Anatomy of the Parts concerned in the Operation. — It Avill 
facilitate the proper comprehension of the operation, and render an 
avoidance of its possible dangers more easy, if the anatomical relations 
of the parts concerned are briefly described. 

The abdominal incision extends from a point an inch above the ante- 
rior superior iliac spine, and is carried, with a slight downward curve, 
parallel to Poupart's ligaments until it reaches a point one inch and 
three-quarters above, and to the outside of, the spine of the pubes. 
Eeyond the latter point it must not extend, so as to avoid the risk of 
wounding the round ligament and the epigastric artery. In this incis- 
ion the skin, the aponeurosis of the external oblique, and the fibres of 
the internal oblique and transversalis muscles are divided. The rectus 
is not implicated. After the muscles are divided the transversalis fascia 
is reached. It is fortunately rather dense in this situation, and is sep- 
arated from the peritoneum bv a laver of connective tissue containing; 
fat. 

The superficial epigastric artery is necessarily divided, but is too 
small to give any trouble. The internal epigastric is fortunately not 
divided, but is so near the inner end of the incision that it may acci- 
dentally be so. In one of Dr. Skene's operations it was laid bare. 
Starting from the external iliac about a quarter of an inch above Pou- 
part's ligament, it runs downward, forward, and inward to the ligament, 
thence it turns upward and inward, in front of the round ligament and 
to the inner side of the internal abdominal ring, behind the posterior 
layer of the sheath of the rectus muscle, which it finally enters. The 
circumflex iliac artery also rises from the external iliac a little below 
the epigastric. It runs between the peritoneum and Poupart's ligament 
until it reaches the crest of the ilium, to the inner side of which it runs. 
It thus lies altcJgether below the line of the incision, and is not likely 
to be injured. 

After the transversalis fascia is divided the peritoneum is reached, 
and is readily lifted up iutact, so as to expose the upper part of the 
vagina, through which the fcetus is extracted. It is fortunate, as facil- 
itating this manoeuvre, that the peritoneum is much more lax than in 
tlie non-pregnant state, and it has been found very easy to lift it out of 
the way in all the operations hitherto performed. 

The division of the vagina is the part of the operation likely to give 
rise to most trouble and risk. It is to be noted that in cases of pelvic 
contraction calling for this operation the uterus with its contents will be 
al)normally high and altogether above the pelvic brim; the vagina is 
therefore necessarily elongated and brought more readily within reach. 
It is enlarged in its upper part during pregnancy, and thrown into 
folds ready for dilatation diu'ing the passage of the child. It is loosely 
surrounded by the other tissues, and is composed of muscular fibres 
easily separable and an internal mucous layer. Its vascular arrange- 
ments are very complex, and the risk of hemorrhage is one of the prom- 
inent dilficulties of the operation. 

In Baudelocque's attempt, in which the vagina was cut instead of 
torn, the loss of blood was so great as to lead to a discontinuance of 
the operation. The arteries are numerous, consisting of branches from 



LA PA R 0-EL y TR TOMY. 6Z*7 

the hypogastric, inferior vesical, internal piulic, and hemorrhoidal. The 
veins form a network surrounding the whole canal, but are largest at 
its extremities, so that it is desirable to open the vagina as low down as 
possible. 

Behind the vagina lies the pouch of peritoneum known as Douglas' 
space, and below that the rectum. In front of it lies the bladder, and 
the risk of injuring that viscus or the ureter entering it constitutes 
another of the dangers of the operation. The relations of these ])arts 
have been specially studied by Garrigues ^ with the view of facilitating 
the safe performance of the operation, and I quote his description : 

" The anterior superior surface of the vagina is in its upper part 
bound by loose connective tissue to the bladder on a surface that has 
the shape of a heart. In the lower or anterior part the boundary-line 
of this surface runs parallel to, and a little outside of, the trigonum vesi- 
cale. In the upper part it follows the outline of the vagina, from which 
it passes over to the cervix. The distance from the internal opening of 
the urethra to the neck of the womb is one inch and a quarter (3.2 
centimeters). The bladder extends five-eighths of an inch (1.5 centi- 
meters) upon the cervix. It is very liable to be reached by the vaginal 
rent if the latter is made too high up or too horizontal. The lower 
part of the antero-superior wall carries in the middle line the urethra. 
In the uppermost part, a little outside of and behind the bladder, lies 
the ureter. In order to avoid the ureter and the bladder the incision 
of the vagina should be made nearly an inch and a half (3.8 centime- 
ters) below the uterus, and in a direction parallel to the ureter and the 
boundary-line between the bladder and the vagina.'' 

The Operation. — The operation has hitherto been performed on the 
right side only. In consequence of the position of the rectum on the 
left, it seems doubtful if the difficulties of performing it on that side 
would not render the operation impossible. This point can only be 
cleared up by experience, and in the mean time the right side should 
certainly be selected. [This is an error, as the operations of Hime of 
Sheffield, Dandridge of Cincinnati, and Poullet of Lyons, in 1878, 
1883, and 1885, respectively, were all performed upon the left side. In 
no case of the three was the bladder injured. — Ed.] For the proper 
performance of the operation four assistants are necessary, besides one 
who administers the anaesthetic. The patient is placed on her })ack on 
the operating-table, with the ])elvis raised and in the same position as 
for ovariotomy. In consequence of access of air per rafjiiutm strict 
antiseptic precautions cannot be adopted. Befn-e commencing the ope- 
ration the cervix is dilated as much as possible by Barnes' bag-s, assisted, 
if necessary, by digital dilatation. 

The operator stands on the riglit side of the patient, while an assistant, 
standing on her left, lays his hand on the uterus and draws it upward and 
to the left, so as to put tlie skin on tlie stretch. The incision is com- 
menced at a point one inch above the anterior superior spine of the 
ilium, and is carried inward in a slightly ciu'ved direction until it 
reaches a point one and three-quarter inches above and outside the spine 
of tlie ])uIh\'>!. The skin and nuiscidar and aponeurotic tissues are cart^ 



538 OBSTETRIC OPERATIONS. 

fully divided layer by layer, any arterial branches being secured as they 
are severed, until the transversalis fascia is reached. This is raised by 
a fine tenaculum, and an aperture is made in it through which a direc- 
tor is introduced, and on this the fascia is divided in the whole length 
of the superficial incision. The operator now separates the peritoneum 
from the transversalis and iliac fascia with his fingers, and an assistant, 
placed on his left, elevates it, as well as the contained intestines, by 
means of a fine warmed napkin, and keeps it well out of the way during 
the rest of the operation. A third assistant now introduces a silver 
catheter into the bladder, and holds it in the position of the boundary- 
line between it and the vagina, and below the uterus. 

A blunt wooden instrument like the obturator of a speculum is intro- 
duced into the vagina, which is pushed up by it above the ilio-pectineal 
line. On this an incision is made by Paquelin's thermo-cautery heated 
to a red heat only, as far below the uterus as possible, and parallel to 
the ilio-pectineal line and the catheter felt in the bladder. AVhen the 
vagina has been burnt through, the index fingers of both hands are 
pushed through the incision, and the vagina torn through as far forward 
as is deemed safe by the guide of the catheter in the bladder, and as 
far backward as possible. AVhen this has been done the uterus is 
depressed to the left, and the cervix lifted into the incision by the 
fingers, and the membranes are ruptured. Through the cervix thus 
elevated the child is extracted, according to the presentation, either by 
simple traction by the forceps or by turning. Before concluding the 
operation the bladder should be injected with milk to make sure that it 
has not been wounded. Should it be so, the laceration may be at once 
united by carbolized gut. The principal risk at this stage is hemorrhage 
from the vaginal vessels, which, however, fortunately, did not give rise 
to much trouble in any of the recent operations. If it occurs it must be 
dealt with as best we can, either by ligature, by the actual cautery, or by 
thoroughly plugging the vaginal wound with cotton-wool both through 
the incision and per vaginam. Tf the latter be not necessary, the wound 
should be cleaned by injecting a warm solution of weak carbolized water 
(2 per cent.), its edges united by interrupted sutures, and dressed as is 
deemed best. The subsequent treatment must be conducted on general 
surgical principles, and will much resemble that necessary after other 
severe abdominal operations, such as ovariotomy. The vagina should be 
gently syringed two or three times daily with a weak antiseptic lotion. 
The diet should be light and nutritious, chiefly consisting of milk, beef- 
tea, and the like. Pain, pyrexia, etc. must be treated as they arise. 
[In the race for supremacy laparo-elytrotomy has been left far in the 
rear by the Sanger-Cfesarean and Porro-Csesarean operations. The last 
laparo-elytrotomy on record was performed on September 18, 1887, 
since which date we have reports of 82 Sanger cases with 14 deaths, 
and 29 Porro cases with 3 deaths. It looks as if the operation of Prof. 
Thomas was not in favor. — Ed.] 



THE TRANSFUSION OF BLOOV. 539 



CHAPTEK VIII. 

THE TRANSFUSION OF BLOOD. 

The transfusion of blood in desperate and apparently hopeless 
cases of hemorrhage offers a possible means of rescuing the patient 
which merits careful consideration. It has again and again attracted 
the attention of the profession, but has never become popularized in 
obstetric practice. The reason of this is not so much the inherent 
defects of the operation itself — for quite a sufficient number of success- 
ful cases are recorded. to make it certain that it is occasionally a most 
valuable remedy — but the fact that the operation has been considered 
a delicate and difficult one, and that it has been deemed neces.sary to 
employ a complicated and expensive apparatus which is never at hand 
when a sudden emergency arises. Whatever may be the difference of 
opinion about the vahie of transfusion, I think it must be admitted that 
it is of the utmost consequence to simplify the process in every possible 
way, and it is above all things necessary to show that the steps of the 
operation are such as can be readily performed by any ordinarily quali- 
fied practitioner, and that the apparatus is so simple and portable as to 
make it easy for any obstetrician to have it at hand. There are com- 
paratively few who would consider it worth while to carry about with 
them, in ordinary e\^ery-day work, cumbrous and expensive instruments 
which may never be required in a lifelong practice ; and hence it is not 
unlikely that in many cases in which transfusion might liave proved 
useful the opportunity of using it has been allowed to slip. Of late 
years the operation has attracted much attention, the method of per- 
forming it has been greatly simplified, and I think it will be easy to 
prove that all the essential apparatus may be purchased for a few 
shillings, and in so portable a form as to take up little or no room, 
so that it may be always carried in the obstetric bag ready for any 
possible emei'gency. 

History of the Operation. — The history of the operation is of con- 
siderable^ interest. In Villari's Life of Saroiutrola it is said to have been 
employed in the case of Pope Innocent A'lII. in the year 141^2, but I 
am not aware on what authority the statement is made. The tirst 
serious proposals for its performance do not seem to have been made 
until the latter half of the seventeenth centiirv. It was tirst actually 
performed in France by Denis of Montpellier, although Ltnver ot' 
Oxford had previously made experiments on animals which satistiinl 
him that it might be undertaken with success. In XovcMuber, UU>7, 
some months after Denis' case, Lowim' nvddc a public exjun-imoni at 
Arundel House in which twi^lve ounces of sheep's bUnxl were injected 
into the veins oi' a healthy man, who is stated to have been verv wol! 
after the operation, which nuist, theretore, have proved siiceesst'id. 



540 OBSTETRIC OPERATIONS. 

These nearly simultaneous cases gave rise to a controversy as to priority 
of invention, which was long carried on with much bitterness. 

The idea of i-esorting to transfusion after severe hemorrhage does not 
seem to have been then entertained. It was recommended as a means 
of treatment in various diseased states or with the extravagant hope of 
imparting new life and vigor to the old and decrepit. The blood of the 
lower animals only was used ; and under these circumstances it is not 
surprising that the operation, although practised on several occasions, 
was never established as it might have been had its indications been 
better understood. 

From that time it fell almost entirely into oblivion, although experi- 
ments and suggestions as to its applicability were occasionally made, 
especially by Dr. Harwood, professor of anatomy at Cambridge, who 
published a thesis on the subject in the year 1785. He, however, never 
carried his suggestions into practice, and, like his predecessors, only 
proposed to emj^loy blood taken from the lower animals. In the year 
1824, Dr. Blundell published his well-known work, entitled Researches, 
Physiological and Pathological, which detailed a large number of experi- 
ments ; and to that distinguished physician belongs the undoubted merit 
of having brought the subject prominently before the profession, and 
of pointing out the cases in which the operation might be performed with 
hopes of success. Since the publication of this work transfusion has 
been regarded as a legitimate operation under special circumstances; 
but, although it has frequently been performed with success and in spite 
of many interesting monographs on the subject, it has never become so 
established as a general resource in suitable cases as its advantages would 
seem to warrant. Within the last few years more attention has been 
paid to the subject, and the writings of Panum, Martin, and De Belina 
abroad, and of Higginson, McDonnell, Hicks, Aveling, and Schafer at 
home, amongst others, have thrown much light on many points con- 
nected with the operation. 

Nature and Object of the Operation. — Transfusion is practically 
only employed in cases of profuse hemorrhage connected with labor, 
although it has been suggested as possibly of value in certain other 
puerperal conditions, such as eclampsia or puerperal fever. Theo- 
retically, it may be expected to be useful in such diseases ; but inas- 
much as little or nothing is known of ics practical eifects in these 
diseased states, it is only possible here to discuss its use in cases of 
excessive hemorrhage. Its action is probably twofold : 1st, the actual 
restitution of blood which has been lost ; 2d, the supply of a sufficient 
quantity of blood to stimulate the heart to contraction, and thus to 
enable the circulation to be carried on until fresh blood is formed. 
The influence of transfusion as a means of restoring lost blood must 
be trivial, since the quantity required to produce an effect is generally 
very small indeed, and never sufficient to counterbalance that which 
has been lost. Its stimulant action is no doubt of far more import- 
ance ; and if the operation be performed before the vital energies are 
entirely exhausted, the effect is often most marked. 

Use of Blood taken from the Lower Animals. — In the earliest 
operations the blood used was always that of the lower animals, gen- 



THE TRANSFUSION OF BLOOD. 541 

erally of the sheep. It has been thought by Brown-Sequard and 
others that the blood of some of the lower animals, especially of those 
in which the corpuscles are of smaller si/e than in man, as of the sheep, 
might be used in safety, provided it is not too rich in carbonic acid and 
too poor in oxygen, and injected in small quantity only. Landois,* 
however, has conclusively proved that the blood of any of the lower 
animals has a most injurious effect on the human red corpuscles, ^Yhich 
rapidly become swollen and decolorized, and discharge their coloring 
matter into the serum. It is certain, therefore, that this plan cannot 
be adopted in practice. 

The great practical difficulty in transfusion has always been the coagu- 
lation of the blood very shortly after it has been removed from the body. 
When fresh-drawn blood is exposed to the atmosphere the fibrin com- 
mences to solidify rapidly, generally in from three to four minutes, 
sometimes much sooner. It is obvious that the moment fibrination 
has commenced the blood is, ipso facto, unfitted for transfusion, not 
only because it can be no longer passed readily through the injecting 
apparatus, but because of the great danger of propelling small masses 
of fibrin into the circulation, and thus causing embolism. Hence, if 
no attempt be made to prevent this difficulty it is essential, no matter 
what apparatus is used, to hurry on the operation so as to inject before 
fibrination has begun. This is a fatal objection, for there is no opera- 
tion in the whole range of surgery in which calmness and deliberation 
are so essential, the more so as the surroundings of the patient in these 
unfortunate cases are such as to tax the presence of mind and coolness 
of the practitioner and his assistants to the utmost. 

All the recent improvements have had for their object the avoidance 
of coagulation, and practically this has been effected in one of three 
ways: 1st, by immediate transfusion from arm to arm, without allow- 
ing the blood to be exposed to the atmosphere, according to the niethods 
proposed by Aveling, Roussel, and Schiifer ; 2d, by adding to the blood 
chemical reagents which have the property of preventing coagulation ; 
3d, removal of the fibrin entirely by promoting its coagulation and 
straining the blood, so that the liquor sanguinis and blood-corpuscles 
alone are injected. 

Inasnuich as the success of the operation altogether depends on the 
method adopted, it will be Avell, before going further, to consider briefiy 
the advantages and disadvantages of each of these plans. 

Aveling's Method. — The method of immediate transfusion has been 
brought prominently before the profession by Dr. Avoling, who has 
invented an ingenious apparatus for }HM-forming it. The apj^aratus 
consists essentially of a minature lligginson's syringe without valves, 
and with a small silver canula at either end. One canuhi is inserted 
into the vein of the person su[)plying blood, the other into a vein of 
tlie patient, and by a curious manipulation of the syringe, subst\]uently 
to be described, the blood is carried from one vein into the other. It 
must be admitted that if there were no practical difficulties this instru- 
ment would be admirable, and it is therelbre not surprising that it 
should have met with so much favor tVoni the profession. 1 cannot 

^ Dk Transfusion dcs Ulnks, Leipzig-. ISTo. 



542 OBSTETRIC OPERATIONS. 

but think, however, that the operation is not so simple as at first siglit 
appears, and tliat therefore it wants one of the essential elements 
required in any procedure for performing transfusion. One of my 
objections is that it is by no means easy to work the apparatus without 
considerable practice. Of this I have satisfied myself by asking mem- 
bers of my class to work it after reading the printed directions, and 
finding that they are not always able to do so at once. Of course it may 
be said that it is easy to acquire the necessary manipulative skill ; but 
when the necessity for transfusion arises there is no time left for prac- 
tising with the instrument, and it is essential that an apparatus to be 
universally applicable should be capable of being used immediately 
and without previous experience. Other objections are — the necessity 
of several assistants, the uncertainty of there being a sufficient circula- 
tion of blood in the veins of the donor to afford a constant supply, and 
the possibility of the whole apparatus being disturbed by restlessness or 
jactitation on the part of the patient. For these reasons it seems to me 
that this plan of immediate transfusion is not so simple nor so generally 
applicable as defibrination. Still, it is impossible not to recognize its 
merits, and it is certainly well worthy of further study and investi- 
gation. 

Roussel's Method. — Another method of immediate transfusion is 
that recommended by Roussel,^ whose apparatus has recently attracted 
considei^able attention. It possesses many undoubted advantages, and 
is beyond doubt a valuable addition to our means of performing the 
operation. It has, however, the great disadvantage of being costly and 
complicated, and hence I do not believe that it is likely to come into 
general use. 

Schafer's Method. — The third method is that recommended by Dr. 
Schafer in his, recent excellent reports on transfusion submitted to the 
Obstetrical Society.^ Schafer suggests two methods of performing the 
operation — one from vein to vein, the other from artery to artery. The 
latter, he holds, has the advantage of supplying pure oxygenated blood 
under the best possible conditions for securing the amelioration of a 
patient suffering from the effects of profuse hemorrhage. The neces- 
sary operative proceedings are, however, somewhat complicated, and it 
seems to me very doubtful if this plan is likely to be at all commonly 
used. His method of immediate transfusion, however, is very simple 
and is well worthy of trial. In his experiments on the lower animals 
it answered admirably. I am not aware that it has yet been tried on the 
human subject, but I do not see any practical difficulty in its applica- 
tion. For the description of the operation I have inserted Dr. Schafer's 
own directions for the performance of both arterial and venous imme- 
diate transfusion. 

The second plan for obviating the bad effects of clotting is the addi- 
tion of some substance to the blood which shall prevent coagulation. 
It is well known that several salts have this property, and the experi- 
ments made in the case of cholera patients prove that solutions of some 
of them may be injected into the venous system without injury. This 

^ Obstetrical Transactions for 1876, vol. xviii. p. 280. 
Ubid., for 1879, vol. xxi. p. 316. 



THE TRANSFUSION OF BLOOD. 043 

method has been specially advocated by Dr. Braxton Hicks, who usas 
a solution of three ounces of fresh phosphate of soda in a pint of 
water, about six ounces of which are added to the quantity of blood 
to be injected. He has narrated 4 cases ^ in which this plan was adopted 
successfully, so far as the prevention of coagulation was concerned. It 
certainly enables the operation to be performed with deliberation and 
oare, but it is somewhat complicated, and it may often happen that the 
necessary chemicals are not at hand. A further objection is the bulk 
of fluid which must be injected, and there is reason to believe that this 
has in some cases seriously embarrassed the heart's action and interfered 
with the success of the operation. In many of the successful cases of 
transfusion the amount of blood injected has been very small, not more 
than two ounces. Dr. Richardson proposes to prevent coagulation by 
the addition of liquor ammonise to the blood in the proportion of two 
minims diluted with twenty minims of water to each ounce of blood. 
Defibrination of the Blood. — The last method, and the one ^vhich, 
on the whole, I believe to be the simplest and most effectual, is defibrina- 
tion. It has been chiefly practised in Great Britain by Dr. McDonnell 
of Dublin, who has published several very interesting cases in which 
he employed it, and by Martin of Berlin and De Belina of Paris. 
The process of removing the fibrin is simple in the extreme, and 
occupies a few minutes only. Another advantage is that the blood to 
be transfused may be prepared quietly in an adjoining apartment, so 
that the operation may be performed with the greatest calmness and 
deliberation, and the donor is spared the excitement and distress which 
the sight of the apparently moribund patient is apt to cause, and which, 
as Dr. Hicks has truly pointed out, may interfere with the free flow of 
blood. The researches of Panum, Brown-Sequard, and others have 
proved that the blood-corpuscles are the true vivifying element, and 
that defibrinated blood acts as well in every respect as that containing 
fibrin. It has been proved that the fibrin is reproduced within a short 
time,^ and the whole tendency of modern research is to regard it, not as 
an essential element of the blood, but as an excrementitious product 
resulting fi-oni the degradation of tissue, which may therefore be advan- 
tageously removed. Another advantage derived from defibrination is 
that the corpuscles are freely exposed to the atmosphere, oxygen is taken 
up, and carbonic acid given ofl*, and the dangers which Brown-Soqnard 
has shown to arise from i\\Q use of blood containing too nuich carlionio 
acid are thereby avoided. There can be, therefore, no physiological 
objection to i\\Q. removal of the fibrin, which, moreover, takes away all 
practical ditficulty from the operation. The straining to which the 
defibrinated blood is subjected entirely prevents the possibility of even 
the most minute particle of fibrin being contained in the injected fluid : 
the risk from embolism is therefore less than in anv of the other pro- 
cesses already reierred to. My own experience o\' this plan is limiteil 
to 8 cases, but in 2 it answered so well that I can conceive no reason- 
able objection to it. I should be inclintxl to say that transt'usion, 
thus performed, is aihongst the simplest of surgical operations — an 

' (^f//'.s' Hospital Reports, 1809, vol. xiv., avl sorios. p. 1. 
M*aiiuiu, 1 irchoivs Arch., vol. xxvii. 



544 OBSTETRIC OPERATIONS. 

opinion which the experience of McDonnell and others fully con- 
firms. 

Transfusion of Milk. — Recently the intravenous injection of freshly- 
drawn warm milk has been recommended as a substitute for blood, 
chiefly in America, It was first used by Dr. Hodder of Toronto, but 
has been introduced and strongly advocated by Thomas of New York, 
who has used it twice after ovariotomy. Brown-Sequard in experi- 
menting on the lower animals found that it ansAvered as well as either 
fresh or defibrinated blood, and about half an hour after the injection 
no trace of the milk-corpuscles could be found in the blood. Schafer, 
however, found that the action of milk on the blood-corpuscles was 
highly deleterious, and that it introduces the germs of septic organisms 
likely to produce very serious results. He therefore pronounces strongly 
against its use. 

Statistical Results. — The number of cases of transfusion are per- 
haps not sufficient to admit of completely reliable conclusions. It is 
certain, however, that transfusion has often been the means of rescuing 
the patient when apparently at the point of death after all other means 
of treatment had failed., Professor Martin records 57 cases, in 43 of 
which transfusion was completely successful, and in 7 temporarily so, 
while in the remaining 7 no reaction took place. Dr. Higginson of 
Liverpool has had 15 cases, 10 of which were successful. Figures such 
as these are encouraging, and they are sufficient to prove that the opera- 
tion is one which at least offers a fair hope of success, and which no 
obstetrician would be justified in neglecting Avhen the patient is sinking 
from the exhaustion of profuse hemorrhage. It is to be hoped also 
that further experience may prove it to be of value in other cases in 
which its use has been suggested, but not, as yet, put to the test of 
experiment. 

Possible Dangers of the Operation. — The possible risks of the 
operation would seem to be the danger of injecting minute particles of 
fibrin, which form emboli, of bubbles of air, or of overwhelming the 
action of the heart by injecting too rapidly or in too great quantity. 
These may be, to a great extent, prevented by careful attention to the 
proper performance of the operation, and it does not clearly appear, 
from the recorded cases, that they have ever proved fatal. AVe must 
also bear in mind that transfusion is seldom or never likely to be 
attempted until the patient is in a state which would otherAvise almost 
certainly preclude the hope of recoA^ery, and in Avhich, therefore, much 
more hazardous proceedings Avould be fully justified. 

Cases Suitable for Transfusion. — The cases suitable for transfusion 
are those in AA^hich the patient is reduced to an extreme state of exhaus- 
tion from hemorrhage during or after labor or miscarriage, AAdiether by 
the repeated losses of placenta pr^evia or the more sudden and profuse 
flooding of post-partum hemorrhage. The operation Avill not be con- 
templated until other and simpler means have been tried and failed, or 
until the symptoms indicate that life is on the verge of extinction. If 
the patient should be deadly pale and cold, Avith no pulse at the wrist 
or one that is scarcely perceptible ; if she be unable to SAA^alloAV or \^omits 
incessantly ; if she lie in an unconscious state ; if jactitation or convul- 



THE TRANSFUSION OF BLOOD. 



545 



sions or repeated faintings should occur ; if the respiration be laborious 
or very rapid and sighing ; if the pupil do not act under the influence 
of light, — it is evident that she is in a condition of extreme danger, 
and it is under such circumstances that transfusion, performed suffici- 
ently soon, offers a fair prospect of success. It does not necessarily 
follow because one or other of these symptoms is present that there is no 
chance of recovery under ordinary treatment, and indeed, it is within 
the experience of all that patients have rallied under apparently the 
most hopeless conditions. But when several of them occur together 
the prospect of recovery is nuich diminished, and transfusion would 
then be fully justified, especially as there is no reason to think that a 
fatal result has ever been directly traced to its employment. Indeed, 
like most other obstetric operations, it is more likely to be postponed 
until too late to be of good service than to be employed too early ; and 
in some of the cases reported as unsuccessful it was not performed until 
respiration had ceased and death had actually taken place. It has some- 
times been said that transfusion should never be employed if the uterus 
be not firmly contracted, so as to prevent the injected blood again escap- 
ing through the uterine sinuses. The cases in which this is likely to 
occur are few ; and if one were met with the escape of blood could be 
prevented by the injection into the uterus of the perchloride of iron. 

Description of the Operation. — In describing the operation I shall 
limit myself to an account of Aveling's and Schafer's method of imme- 
diate transfusion, and to that of injecting defibrinated blood. I con- 
sider myself justified in omitting any account of the numerous instru- 
ments which have been invented for the purpose of injecting pure blood, 
since I believe the practical difficulties are too great ever to render this 
form of operation serviceable. The great objection to most of them is 
their cost and complexity ; and as long as any special apparatus is con- 
sidered essential, the full benefits to be derived from transfusion are not 



Fig. 194. 




MeUiod of Transfusion )n- Avoling't; Appimitus. 



likely to be realized. The necessity lor employing it arises suddenlv : it 
may be in a locality in which it is impossible to procure a special instru- 



546 OBSTETBIC OPEBATIOXS. 

ment ; and it Tvould be well if it were understood that transfusion mav 
be safely and eiFectually perforroed by the simplest means. In many 
of the successful cases an ordinary syringe was used ; in one, in the 
absence of other instruments, a child's toy syringe was employed. I 
have myself performed it with a simple syringe purchased at the nearest 
chemist's shop when a special transfusion apparatus failed to act satis- 
factorily. 

In immediate transfusion (Fig. 194) the donor is seated close to the 
patient, and, the veins in the arms of each having been opened, the 
silver canula at either end of the instrument is introduced into them 
(a b). The tube between the bulb and the donor is now pinched (d), 
so as to form a vacuum, and the bulb becomes filled with blood from 
the donor. The finger is now removed so as to compress the distal tube 
(d'), and, the bulb being compressed (c), its contents are injected into 
the patient's vein. The bulb is calculated to hold about two drachms, 
so that the amount injected can be estimated by the number of times it 
is emptied. The risk of injecting air is prevented by filling the syringe 
with water, which is injected before the blood. 

Schafer's Dieectioxs for Immediate Traxsfusiox. 

Direct Venous Transfasion. — " Procure two glass canulas of appro- 
priate size and shape (see Fig. 195), and a piece of black india-rubber 
tubing seven inches long, and not less than a quarter of an inch bore, 
fitted to the canulas. This apparatus could always be 
Fig. 195. improvised. 

" Place the transfusion-tube in a basin of hot water 
containing a little carbonate of soda. Put a tape 
round the arm of the patient just below the place 
where the vein is to be opened, and another just above. 
Expose the vein by an incision through the skin, which 
should be made transversely if the position of the vein 
cannot be made out through the skin. Clear a small 
piece of the vein with forceps and slip a pointed piece 
of card underneath it. By a snip with scissors make an 
oblique opening into the vein, and partly insert a small 
blunt instrument (stich as a wool-needle), so that the 
aperture is not lost. Remove the upper tape. Xext 
prepare the vein of the giver. To do this put tapes 
around the arm just below and above the place where the vein is to 
be opened. Expose the vein by a longitudinal incision through the 
skin. Clear a small piece of the vessel with forceps and pass a thread 
ligature underneath. A slip of card may also be placed under this vein. 
Make a snip into the vein just above the ligature, and then, taking the 
transfusion-tube out of the soda solution, slip one of the canulas into 
the vein of the giver and tie it in with a simple knot, which can be 
readily untied. Let the giver go to the bedside and place his arm 
alongside that of the patient. Hold the end of the india-rubber tube 
with the second canula up a little, and release the lower tape on the arm 
of the blood-o'iver. As soon as the blood flows out of the second 




THE TRANSFUSION OF BLOOD. 547 

canula pinch the india-rubber tube close to the canula, so as to stop the 
flow, and, removing the wool-needle, slip the end of the canula into the 
vein of the patient ; hold it there, and allow the blood to pass freely 
along the tube. Three minutes will generally be long enough for the 
flow, which can be stopped by compressing the vein of the giver below 
the canula. Both canulas may now be withdrawn and the ligature 
removed from the vein of the giver, the cut veins being dealt with in 
the usual way. Of course, the other tape on the arm of the donor must 
be removed as soon as the transfusion is over. 

" Instead of using the transfusion-tube empty, it may be filled with 
soda solution, to the exclusion of air. It is necessary to have one or 
two spring clips on the tube to prevent the escape of the solution. This 
is a much better plan than the other, for the blood need not be allowed 
to flow into the tube until the second canula is inserted, and then by 
opening the clips it may drive the soda solution before it into the vein. 
The small quantity of carbonate-of-soda solution necessary to fill the 
simple tube will do the patient no harm. 

" In the first place, we have to determine what artery or arteries 
would be most available for the purpose. The (left) radial artery could 
be most easily dealt with, and its use would involve less subsequent 
inconvenience to the donor of the blood than any other. But if it is 
considered necessary to choose some other artery, I think the dorsal 
artery of the foot should be selected, for its employment presents sev- 
eral advantages. It is a minor artery, but nevertheless large enough 
for the insertion of a canula ; it is comparatively superficial and pretty 
easily found ; and by causing the person yielding the blood to stand up 
a great amount of pressure may be obtained in it. In the bloodless 
patient, especially if there be much subcutaneous fat, this artery might 
not be readily found. 

Apparatus Required. — "A piece of india-rubber tubing six or 
seven inches long, two glass canulas of appropriate size and shape, and 
some spring clips, two of which should be small for compressing the 
arteries, the others larger and adapted for clipping the tube. The 
smaller clips might be dispensed with, and ligatures fastened with a 
slip bow might be used instead, in the way Lower reconnnended. Be- 
fore commencing it is important to ensure that the india-rubber tube 
cannot slip ofl' the canulas. It ought to be secured to them by tight 
ligatures or by binding wire. This precaution is necessary because the 
arterial blood is under considerable pressure. This would tenil to Ibive 
the tubes apart and might cause copious hemorrhage. 

" The transfusion-tube is to be placed as before in carbonato-of-soda 
solution. 

Procedure. — "The artery of the patient nuist first be exposed. To 
do this make an incision an incli in le^ngth through the skin over the 
line of the artery, and then divide to an equal extent the subcutaneous 
tissue and fascia wliich cover it. About three-quartei-s oi' an inch iu 
length of the vessel is to be separated from the ensheathing connective 
tissue and from its accompanying veins by slipping a blunt instrument, 
such as an ancHU'ism-needle or the blade oi' a forceps, undornoath and 
moving it up and ilown. A small piece of card, cut into a long trian- 



548 OBSTETRIC OPERATIONS. 

gular shape, may then be placed under instead of the needle. A liga- 
ture is then tied tightly around the lower end of the piece of artery, 
another is looped loosely around the middle, and a spring clip is put on 
close to the upper end. The vessel may now be opened just above the 
lower ligature by a snip with the scissors. 

^^ If the artery have any branch at the exposed part, this ought to be 
tied before commencing to isolate the vessel. In the person who is to 
yield the blood exactly the same process is carried out. 

^^The transfusion-tube is next filled (by suction) with soda solution, 
and this is prevented from escaping by one or two spring clips on the 
tube. 

" One of the glass terminals is tied into the artery of the giver, and 
the other into the artery of the patient, the ends of both being directed 
toward the heart. 

" All is now ready for the transfusion. To effect this, remove the 
clips on the india-rubber tube and open the clip on the artery of the 
patient ; then open — not remove — that on the artery of the giver, and 
keep it open one minute, or a little longer if it seems advisable. Allow 
the clips to close again, and if the patient's condition is ameliorated the 
operation may be ended by tying the arteries — first that of the giver, 
then that of the patient — -just above the clips. 

^' Finally, cut out and remove the canulas, together with the pieces of 
artery into which they are tied." 

Injection of Defibrinated Blood. — For injecting defibrinated blood 
various contrivances have been used. McDonnelFs instrument is a 
simple cylinder with a nozzle attached, from which the blood is pro- 
pelled by gravitation. When the propulsive power is insufficient, 
increased pressure is applied by breathing forcibly into the open end of 
the receiver. De Belina's instrument is on the same principle, only 
atmospheric pressure is supplied by a contrivance similar to Richard- 
son's spray-producer attached to one end. The idea is simple, but there 
is some doubt of a gravitation instrument being sufficiently powerful, 
and it certainly failed in my hands. I have had valves applied to 
Aveling's instrument, so that it works by compression of the bulb, like 
an ordinary Higginson's syringe. This, with a single silver canula at 
one end for introduction into the vein, forms a perfect and inexpensive 
transfusion apparatus, taking up scarcely any space. If it be not at 
hand, any small syringe with a tolerably fine nozzle may be used. 

The first step of the operation is defibrination of the blood, which 
should, if possible, be prepared in an apartment adjoining the patient's. 
The blood should be taken from the arm of a strong and healthy man. 
The quality cannot be unimportant, and in some recorded cases the fail- 
ure of the operation has been attributed to the fact of the donor having 
been a weakly female. The supply from a woman might also prove 
insufficient ; and although it has been shown that blood from two or 
more persons may be used with safety, yet such a change necessarily 
causes delay, and should, if possible, be avoided. A vein having been 
opened, eight or ten ounces of blood are withdrawn and received into 
some perfectly clean vessel, such as a dessert finger-glass. As it flows 
it should be briskly agitated with a clean silver fork or a glass rod, and 



THE TRANSFUSION OF BLOOD. 549 

very shortly strings of fibrin begin to form. It is now strairted through 
a piece of fine muslin, previously dipped in hot water, into a second 
vessel which is floating in water at a temperature of about 105°. By 
this straining the fibrin and ail air-bubbles resulting from the agitation 
are removed, and if there be no excessive hurry it might be well to 
repeat the straining a second time. If the vessel be kept floating in 
warm water, the blood is prevented from getting cool, and we can now 
proceed to prepare the arm of the patient for injection. 

This is the most delicate and difficult part of the operation, since the 
veins are generally collapsed and empty, and by no means easy to find. 
The best way of exposing them is that practised by McDonnell, who 
pinches up a fold of the skin at the bend of the elbow and transfixes 
it with a fine tenotomy-knife or scalpel, so making a gaping wound in 
the integument, at the bottom of which they are seen lying. A probe 
should now be passed underneath the vein selected for opening, so as to 
avoid the chance of its being lost at any subsequent stage of the opera- 
tion. This is a point of some importance, and from the neglect of this 
precaution I have been obliged to open another vein than that origi- 
nally fixed on. A small portion of the vein being raised with the for- 
ceps, a nick is made into it for the passage of the canula. 

Injection of the Blood. — The prepared blood is now brought to the 
bedside, and, the apparatus having been previously filled with blood to 
avoid the risk of injecting any bubbles of air, the canula is inserted 
into the opening made in the vein and transfusion commenced. It 
should be constantly borne in mind that this part of the operation 
should be conducted with the greatest caution, the blood introduced 
very slowly, and the effect on the patient carefully watched. The injec- 
tion may be proceeded with until some perceptible effect is produced, 
which will generally be a return of the pulsation, first at the heart and 
subsequently at the wrist, an increase in the temperature of the body, 
greater depth and frequency of tlie respirations, and a general appear- 
ance of returning animation about the countenance. Sometimes the 
arms have been thrown about or spasmodic twitchings of the face have 
taken place. The quantity of blood required to produce these effects 
varies greatly, but in the majority of cases has been very small. Occa- 
sionally 2 ounces have proved sufficient, and the average may be taken 
as ranging between 4 and 6, although in a few cases between 10 and 20 
have been used. The practical rule is to proceed very slowly with the 
injection until some perceptible result is observed. Should embarrassed 
or frequent respiration supervene, we may suspect that we have been 
injecting either too great a quantity of blood or with too nuich tbrce 
and rapidity, and the operation should at once be suspended, and not 
resumed until the sus[)i('ious symptoms have passed away. It mav hap- 
pen that the elfects of the transfusion have been highly satistactorv, but 
that in the coiu'se of time there is evidence of returning svncope. This 
may possibly be prevented by the administration ot* stinudants; but if 
these fail there is no reason wliy a fresh supply oi' blood shoidd not 
again be injected, but this should be done before the etlects of the first 
transfusion have entirely passed away. 

Secondary Effects of Transfusion. — The subsecpient etlects in 



550 OBSTETRIC OPERATIONS. 

successful cases of transfusion merit careful study. In some few cases 
death is said to have happened within a few weeks, with symptoms 
resembling pysemia. Too little is known on this point, however, to 
justify any positive conclusions with regard to it. 

[Transfusion with defibrinated blood was, I believe, first tried in 
America by Dr. Joshua G. Allen of Philadelphia on December 30, 
1868, on a woman who suifered from the effects of repeated attacks of 
uterine hemorrhage. Six fluidounces were injected, and the patient 
recovered a reasonable degree of health. In 1869, Dr. Allen repeated 
the operation 4 times, in 2 of the cases being associated with Dr. 
Thomas G. Morton at the Pennsylvania Hospital, and using a double 
vessel for keeping the blood warm, consisting of a conical cup for hold- 
ing the blood and a lower vessel for containing warm water, the two 
being made in one and the temperature ascertained by an outside ther- 
mometer. Dr. Morton repeated the experiment on two other patients 
in 1870 and 1874, the second, a girl of eleven, being operated on twice, 
at intervals of six weeks, for bleeding from the nose and bladder, the 
effect of purpura : she entirely recovered. Dr. M, used a set of instru- 
ments specially designed for the work, and shown in illustration in the 
American Journal of the Medical Sciences, July, 1874, p. 112. Between 
1874 and 1886 he repeated the operation on several hosj^ital and j^rivate 
patients. 

Intravenous saline injections are far more readily used, are safer, 
and are believed from the tests that have been made to be quite as effi- 
cacious as blood. What has been called artificial serum consists of 20 
grammes of suljDhate of soda and 10 grammes of chloride of sodium in 2 
litres of water. The solution should be injected into a large vein slowly 
and in large quantity, as much as a pint or more at a time, and repeated 
at intervals : the flnid should be blood-warm. Another formula consists 
of piu'e common salt IJ fluiddrachms, liquor potassae 1 minim, and 
pure carbonate of potash 45 grains in two quarts of water. — Ed.] 



PART V. 

THE PUERPERAL STATE. 



CHAPTER I. 
• THE PUERPERAL STATE AND ITS MANAGEMENT. 

Importance of Studying" the Puerperal State. — The key to the 
management of women after labor, and to the proper imderstanding of 
the many important diseases which may then occur, is to be found in a 
study of the phenomena following delivery and of the changes going^ 
on in the mother's system during the puerperal period. No doubt nat- 
ural labor is a physiological and healthy function, and during recovery 
from its effects disease should not occur. It must not be forgotten, 
however, that none of our patients are under physiologically healthy 
conditions. The surroundings of the lying-in woman, the effects of 
civilization, of erroi-s of diet, of defective cleanliness, of exp*osure to 
contagion, and of a hundred other conditions which it is impossible to 
appreciate, have most important influences on the results of childbirth. 
Hence it follows that labor, even under the most favorable conditions, 
is attended with considerable risk. 

The Mortality of Childbirth. — It is not easy to say with accuracy 
what is the })recise mortality accompanying childbirth in ordinary 
domestic practice, since the returns derived from the reports of the 
Kegistrar-General or from private sources are manifestly open to serious 
error. The nearest approach to a reliable estimate is that made by Dr. 
Matthews Duncan,^ who calculates, from figures derived from various 
sources, that no fewer than 1 out of every 120 women, delivered at or 
near the full time, dies within four weeks of childbirth. This indicates 
a mortality far above that which has been generally believed to atH'oni- 
pany childbearing under favorable circumstances. It, however, closely 
approximates to a similar estimate made by jMcOlintock," who calculates 
the mortality in England and Wales as 1 in 12(), and in the upjHn- and 
middle classes alone, where the conditions may naturally be supposed 
to be more favorable, at 1 in 146; more recently he has come to the 
conclusion, from his own increased experience and the publishcxl results 
of the practice of others, that 1 in 100 would more correctly represent 
the rate of puer{)eral mortality."^ In these calcidations there are some 

^ The "A[or(:ility of CMiildbod,'" FaUu. M<d. Joiirn.. vol. 1S(;*^ 70. \\ o99. 
'^ Ihihlin Quarterly Journ. of Med. Sciciur, I8(>i>. vol. .\lviii. \\ '2o0. 
^ Ih-it. J[(d. Journ., 1878, vol. ii. p. 215. 



552 THE PUERPERAL STATE. 

obvious sources of error, since they include deaths from all causes 
within four weeks of delivery, some of which must have been inde- 
pendent of the puerperal state. 

But it is not the deaths alone which should be considered. All prac- 
titioners know how large a number of their patients suffer from morbid 
states which may be directly traced to the effects of childbearing. It 
is impossible to arrive at any statistical conclusion on this point, but it 
must have a very sensible and important influence on the health of 
childbearing women. 

Alterations in the Blood after Delivery. — The state of the blood 
during pregnancy, already referred to (p. 143), has an important bear- 
ing on the puerperal state. There is hyperinosis, which is largely 
increased by the changes going on immediately after the birth of the 
child, for then the large supply of blood which has been going to the 
uterus is suddenly stopped, and the system must also get rid of a •quan- 
tity of effete matter thrown into the circulation in consequence of the 
degenerative changes occurring in the muscular fibres of the uterus. 
Hence all the depurative channels by which this can be eliminated are 
called on to act with great energy. If, in addition, the peculiar condi- 
tion of the generative tract be borne in mind — viz. the large open ves- 
sels on its inner surface, the partially bared inner surface of the uterus, 
and the channels for absorption existing in consequence of slight lacera- 
tions in the cervix or vagina — it is not a matter of surprise that septic 
diseases should be so common. 

It will be well to consider successively the various changes going on 
after delivery, and then we shall be in a better position for studying 
the rational management of the puerperal state. 

Some degree of nervous shock or exhaustion is observable after 
most labors. . In many cases it is entirely absent; in others it is well 
marked. Its amount is in proportion to the severity of the labor and 
the susceptibility of the patient ; and it is therefore most likely to be 
excessive in women who have suffered greatly from pain, who have 
undergone much muscular exertion, or who have been weakened from 
undue loss of blood. It is evidenced by a feeling of exhaustion and 
fatigue, and not uncommonly there is some shivering, which soon passes 
off, and is generally followed by refreshing sleep. The extreme nervous 
susceptibility continues for a considerable time after delivery, and 
indicates the necessity of keeping the lying-in patient as free from all 
sources of excitement as possible. 

Immediately after delivery the pulse falls, and the importance of this 
as indicating a favorable state of the ])atient has already been alluded 
to. The condition of the pulse has been carefully studied by Blot,^ 
w^ho has shown that this diminution, which he believes to be connected 
with a diminished tension in the arteries due to the sudden arrest of 
the uterine circulation, continues in a large proportion of cases for a 
considerable number of days after delivery ; and as a matter of clinical 
import as long as it does the patient may be considered to be in a favor- 
able state. In many instances tlie slowness of the pulse is remarkable, 
often sinking to 50, or even 40, beats per minute. Any increase above 

1 Arch, gen de Med., 1864. 



THE PUERPERAL STATE AND ITS MANAGEMENT 553 

the normal rate, especially if at all continuous, should always be care- 
fully noted and looked on with suspicion. In connection with this sub- 
ject, however, it must be remembered that in puerperal women the most 
trivial circumstances may cause a sudden rise of the pulse. This must 
be familiar to every practical obstetrician, who has constant opportuni- 
ties of observing this effect after any transient excitement or fatigue. 
In lying-in hospitals it has generally been observed that the occurrence 
of any particularly bad case will send up the pulse of all the other 
patients who may have heard of it. 

The temperature in the lying--in state affords much valuable 
information. During and for a short time after labor there is a slight 
elevation. It soon falls to, or even somewhat below, the normal level. 
Squire found that the fall occurred within twenty-four hours, sometimes 
within twelve hours, after the termination of labor. ^ For a few days 
there is often a slight increase of temperature, especially toward the 
evening, which is probably caused by the rapid oxidation of tissue in 
connection with the involution of the uterus. In about forty-eight 
hours there is a rise connected with the establishment of lactation 
amounting to one or two degrees over the normal level, but this again 
subsides as soon as the milk is freely secreted. Crede has also shown ^ 
that rapid but transient rises of temperature may occur at any period, 
connected with trivial causes, such as constipation, errors of diet, or 
mental disturbances. But if there be any rise of temperature which 
is at all continuous, especially to over 100° Fahr., and associated with 
rapidity of the pulse, there is reason to fear the existence of some com- 
plication. 

The Secretions and Excretions. — The various secretions and excre- 
tions are carried on with increased activity after labor. The skin 
especially acts freely, the patient often sweating profusely. There is 
also an abundant secretion of urine, but not uncommonly a difficulty 
of voiding it, either on account of temporary paralysis of the neck of 
the bladder, resulting from the pressure to which it has been subjected, 
or from swelling and occlusion of the urethra. For the same reason 
the rectum is sluggish for a time, and constipation is not infrequent. 
The appetite is generally indifferent, and the patient is often thirsty. 

Generally in about forty-eight houi's the secretion of milk becomes 
established, and this is occasionally accompanied by a certain amount 
of constitutional irritation. The breasts often become turgid, hot, and 
painful. There may or may not be some general disturbance, quicken- 
ing of pulse, elevation of temperature, possibly slight shivering, and a 
general sense of oppression, whicli are quickly relieved as the milk is 
formed and the breasts em])tied by suckling. Squire says that the 
most constant pluMiomenon counected with the tenq)eraturo is a slight 
elevation as the milk is secreted, rapiiUy falling when lactation is 
established. JWktn* noted elevation either ot' tenijHn-ature ov pulse 
in only 4 out of 52 cases which were carel'ully watched. There can 
be little doubt that the imjHU'tance of the so-called " milk tever " has 
been innnensely exaggerakxl, and its existence as a normal aci'onipani- 

' " Piiorpornl Tompovaturo," Ohietrical Tnvisacdons, 1S(.>S. vol. ix. \\ V2\\ 
'^Monat. f. iichurt., 1S()S. Hd. xxxii. S. 453. 



554 THE PUERPERAL STATE. 

meut of the puerperal state is more than doubtful. It is certain, how- 
ever, that in a small minority of cases there is an appreciable amount 
of disturbance about the time that the milk is formed. Out of 423 
cases, Macau ^ found that in 113, or about 27 per cent., there was no 
rise of temperature; in 226 tlie temperature did rise to 100° and over, 
and of these in 32, or a little over 7 per cent., the only ascertainable 
cause was a painful or distended condition of the breast. Many 
modern writers, such as AVinckel, Griinewaldt, and D'Espine, entirely 
deny the connection of this disturbance with lactation, and refer it to 
a slight and transient septicaemia. Graily Hewitt remarks that it is 
most commonly met with when the patient is kept low and on deficient 
diet after delivery, especially when the system is below par from hemor- 
rhage or any other cause. This observation will no doubt account for 
the comparative rarity of febrile disturbance in connection with lactation 
in these days, in which the starving of puerperal patients is not con- 
sidered necessary. It is certain that anything deserving the name of 
milk fever is now altogether exceptional, and such feverishness as exists 
is generally quite transient. It is also a fact that it is most apt to 
occur in delicate and weakly women, especially in those who do not 
or are unable to nurse. There does not, however, seem to be any 
sufficient reason for referring it, even when tolerably well marked, to 
septicaemia. The relief which attends the emptying of the breasts 
seems sufficient to prove its connection with lactation, and the discom- 
fort which is necessarily associated with the swollen and turgid mammae 
is of itself quite sufficient to explain it. 

In the urine of women during lactation an appreciable amount of 
sugar may readily be detected. The amount varies according to the 
condition of the breasts. It increases when they are turgid and con- 
gested, and is therefore most abundant in women in whom the breasts 
are not emptied, as when the child is dead or when lactation is not 
attempted. 

Contraction of the Uterus after Delivery. — Immediately after 
delivery the uterus contracts firmly, and can be felt at the lower part 
of the abdomen as a hard, firm mass about the size of a cricket-ball 
(Plate v.). After a time it again relaxes somewhat, and alternate 
relaxations and contractions go on at intervals for a considerable time 
after the expulsion of the placenta. The more complete and perma- 
nent the contraction, the greater the safety and comfort of the patient ; 
for when the organ remains in a state of partial relaxation, coagula are 
apt to be retained in its cavity, while for the same reason air enters more 
readily into it. Hence decomposition is favored, and the chances of 
septic absorption are much increased, while even when this does not 
occur the muscular fibres are excited to contract and severe after-pains 
are produced. 

After the first few days the diminution in the size of the uterus pro- 
gresses with great rapidity. By about the sixth day it is so much less- 
ened as to project not more than \^ or 2 inches above the pelvic brim, 
while by the eleventh day it is no longer to be made out by abdominal 
palpation. Its increased size is, however, still apparent per vaginamy 

^ Dublin Quarterly Journ. of Med. Science, 1878, vol. Ixv. p. 435. 



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THE PUERPERAL STATE AND ITS MANAGEMENT oo5 

and should occasion arise for making internal examination^ the mass of 
the lower segment of the uterus, with its flabby and patulous cervix, 
can be felt for some weeks after delivery. This may sometimes be of 
practical value in cases in which it is necessary to ascertain the fact of 
recent delivery, and under these circumstances, as pointed out by Simp- 
son, the uterine sound would also enable us to prove that the cavity of 
the uterus is considerably elongated. Indeed, the normal condition of 
the uterus and cervix is not regained until six weeks or two months 
after labor. These observations are corroborated by investigations on 
the weight of the organ at different periods after labor. Thus, Heschl ^ 
has shown that the uterus immediately after delivery weighs about 22 
to 24 oz.; within a week it weighs 19 to 21 oz., and at the end of the 
second week 10 to 11 oz. only. At the end of the third week it weighs 
5 to 7 oz., but it is not until the end of the second month that it reaches 
its normal weight. Hence it appears that the most rapid diminution 
occurs during the second week after delivery. 

Fatty Transformation of the Muscular Fibres. — The mode in 
which this diminution in size is effected is by the transformation of the 
muscular fibres into molecular fat, which is absorbed into the maternal 
vascular system, which therefore becomes loaded v/ith a large amount 
of effete material. Heschl has shown that the entire mass of the. 
enlarged uterine muscles is removed, and replaced by newly-formed 
fibres, which commence to be developed about the fourth week after 
delivery, the change being complete about the end of the second month. 
Generally speaking, involution goes on without interruption. It is, 
however, apt to be interfered with by a variety of causes,, such as pre- 
mature exertion, intercurrent disease, and very probably by neglect of 
lactation. Hence the uterus often remains large and bulky, and the 
foundation for many subsequent uterine aihricnts is laid. 

Changes in the Uterine Vessels. — Williams has drawn attention 
to changes occurring in the vessels of the uterus, some of which seem 
to be permanent, and may, should further observations corroborate iiis 
investigations, prove of value in enabling us to ascertain whetlier a 
uterus is nulliparous or the reverse — a question which may be of medico- 
legal importance. After pregnancy he found all the vessels enlargai 
in calibre. The coats of the arteries are thickened and hypertrophied, 
and this he has observed even in the uteri of aged ^vomen who have 
not boi-ne chiklren for many years. The venous sinuses, especially at 
the placental site, have their walls gl'eatly thickened and convoluted, 
and contain in their centre a small clot of blood (Fig. 196). This 
thickening attains its greatest dimensions in the third month after gesta- 
tion, but traces of it may be detected as late as ten or twelve weeks after 
labor. 

Chang'es in the Uterine Mucous Membrane. — The changes going 
on in the lining membrane of the utcu'us inunediatelv after delivery 
are of great imjx)rtanc(^ in leading to a knowledge of the puerperal 
state, and have already been disi'ussed when describing the dci'idua 
(p. 105). Its cavity is covered with a rinldish-gray film tbrnunl o\^ bloinl 
and fibrin. The open nu>uths o[' \\w uterine sinuses are still visible, 
' 7i (>•(•((/•( 7/ ('x ()// the Condiivi of the IIuiihui i'tti-u.< aiur Ihiitrnj. 



556 



THE PUERPERAL STATE. 



more especially over the site of the placenta, and throrubi may be seen 
projecting from them. The placental site can be distinctly made out in 
the form of an irregularly oval patch, where the lining membrane is 
thicker than elsewhere. (See Plate V.) 

Contraction of the Vagina, etc. — The vagina soon contracts, and 
by the time the puerperal month is over it has returned to its normal 

Fig. 19t). 




Section of a Uterine Sinus from the Placental Site Nine Weeks after Delivery. 
(After Williams.) 

dimensions, but after childbearing it always remains more lax and less 
rugose than in nulliparae. The vulva, at first very lax and much dis- 
tended, soon regains its former state. The abdominal parietes remain 
loose and flabby for a considerable time, and the white streaks produced 
by the distension of the cutis very generally become permanent. In 
some women, especially when proper support by bandaging has not been 
given, the abdomen remains permanently loose and pendulous. 

The Lochia! Discharge. — From the time of delivery up to about 
three weeks afterward a discharge escapes from the interior of the uterus 
known as the lochia. At first this consists almost entirely of pure 
blood, mixed with a variable amount of coagula. If efficient uterine 
contraction has not been secured after the expulsion of the placenta, 
coagula of considerable size are frequently expelled with the lochia for 
one or two days after delivery. In three or four days the distinctly 
bloody character of the lochia is altered. They have a reddish watery 
appearance, and are known as the lochia rubra or cruenta. According 
to the researches of Wertlieimer,^ they are at this time composed chiefly 
of blood-corpuscles, mixed with epithelium scales, mucous corpuscles, 

1 Virchoiv's Arch., 1861. 



THE PUERPERAL STATE AND ITS MANAGEMENT oo7 

and the debris of the decidua. The change in the appearance of the 
discharge progresses gradually^ and about the seventh or eighth day it 
has uo longer a red color, but is a pale greenish fluid, with a peculiar 
sickening and disagreeable odor, and is familiarly described as the 
"green waters." It now contains a small quantity of blood-corpuscles, 
which lessens in amount from day to day, but a considerable number 
of pus-corj)uscles, which remain the principal constituent of the dis- 
charge until it ceases. Besides these, epithelial scales, fatty granules, 
and crystals of cholesterin are observed. Occasionally a small infuso- 
rium, which has been named the Trichomonas vaginalis ^ has been 
detected, but it is not of constant occurrence. 

The amount of the lochia, varies much, and in some women it is 
habitually more abundant than in others. Under ordinary circum- 
stances it is very scanty after the first fortnight, but occasionally it con- 
tinues somewhat abundant for a month or more, without any bad results. 
It is apt again to become of a red color and to increase in quantity 
in consequence of any slight excitement or disturbance. If this red 
discharge continues for any undue length of time, there is reason to 
suspect some abnormality, and it may not unfrequently be traced to 
slight lacerations about the cervix which have not healed properly. 
This result may also follow premature exertion, interfering with the 
proper involution of the uterus ; and the patient should certainly not 
be allowed to move about as long as much colored discharge is going on. 

Occasionally the lochia has an intensely fetid odor. This must 
always give rise to some anxiety, since it often indicates the retention 
and putrefaction of coagula and involves the risk of septic absorption. 
It is not very rare, however, to observe a most disagreeable odor persist 
in the lochia without any bad results. The fetor always deserves care- 
ful attention, and an endeavor should be made to obviate it by direct- 
ing the nurse to syringe out the vagina freely night and morning with 
Condy's fluid and water; while, if it be associated with quickened pulse 
and elevated temperature, other measures, to be subsequently described, 
will be necessary. 

The after-pains, which many childbearing women dread even more 
than the labor-pains, are irregular contractions occurring for a varying 
time after delivery, and resulting from the efforts of the uterus to expel 
coagula which have formed in its interior. If, therefore, special care 
be taken to secure complete and permanent contraction after labor, they 
rarely occur or to a very slight extent. Their dependence on uterine 
inertia is evidenced by the common observation that they are seldom 
met with in primiparie, in whom uterine contraction may be supposed 
to be more efficient, and are more frequent in women who have borne 
many children. They are a preventable com])licaticHi, and one which 
need not give rise to any anxiety: they are, iniUvd, rather salutary than 
the reverse, for if coagula be retained in utcro, the sooner they are 
expelled the better. The after-pains generally bi>gin a low luniis alter 
delivery, and continue '\\\ bad eases for three or tour days, but seldom 
longer. T^hey are generally increased when the nuunuKv are irritattxi 
by suction. When at their height they are often relieved by the expul- 
sion of the coagula. In some severe cases they are ap[>arently neural- 



558 THE PUERPERAL STATE. 

gic in character, and do not seem to depend on the retention of coagula. 
They may be readily distinguished from pains due to more serious 
causes by feeling the enlarged uterus harden under their influence, by 
the uterus not being tender on pressure, and by the absence of any 
constitutional symptoms. 

The manag-ement of -wonien after childbirth has varied much at 
different times, according to fashion or theory. The dread of inflam- 
mation long influenced the professional mind, and caused the adoption 
of a strictly antiphlogistic diet, which led to a tardy convalescence. 
The recognition of the essentially physiological character of labor has 
resulted in more sound views, with manifest advantage to our patients. 
The main facts to bear in mind with regard to the puerperal woman 
are her nervous susceptibility, which necessitates quiet and absence of 
all excitement; the importance of favoring involution by prolonged 
rest; and the risk of septicaemia, which calls for perfect cleanliness and 
attention to hygienic precautions. 

As soon as we are satisfied that the uterus is perfectly contracted and 
that all risk of hemorrhage is over, the patient should be left to sleep. 
Many practitioners administer an opiate; but as a matter of routine 
this is certainly not good practice, since it checks the contractions of the 
uterus and often produces unpleasant effects. Still, if the labor have 
been long and tedious, and the patient be much exhausted, fifteen or 
twenty drops of Battley's solution may be administered with advan- 
tage. 

Within a few hours the patient should be seen, and at the first visit 
particular attention should be paid to the state of the pulse, the uterus, 
and the bladder. The pulse during the whole period of convalescence 
should be carefully watched, and if it be at all elevated the tempera- 
ture should at once be taken. If the pulse and temperature remain 
normal, we may be satisfied that things are going on well ; but if the 
one be quickened and the other elevated some disturbance or complica- 
tion may be apprehended. The abdomen should be felt, to see that 
the uterus is not unduly distended and that there is no tenderness. 
After the first day or two this is no longer necessary. 

Treatment of Retention of Urine. — Sometimes the patient cannot 
at first void the urine, and the application of a hot sponge over the 
pubes may enable her to do so. If the retention of urine be clue to 
temporary paralysis of the bladder, three or four 20-minim doses of the 
liquid extract of ergot at intervals of half an hour may prove success- 
ful. Many hours should not be allowed to elapse without relieving 
the patient by the catheter, since prolonged retention is only likely to 
make matters worse. Subsequently, it may be necessary to empty the 
bladder night and morning until the patient regain her power over it 
or until tlie swelling of the urethra subsides, and this will generally be 
the case in a few days. Occasionally the bladder becomes largely dis- 
tended, and is relieved to some degree by dribbling of urine from the 
urethra. Such a state of things may deceive the patient and nurse, and 
may produce serious consequences by causing cystitis. Attention to the 
condition of the abdomen will prevent the practitioner from being 
deceived, for in addition to some constitutional disturbance a large, ten- 



THE PUERPERAL STATE AND ITS MANAGEMENT. 559 

der^ and fluctuating swelling will be found in the hypogastric region 
distinct from the uterus, which it displaces to one or other side. The 
catheter will at once prove that this is produced hy distension of the 
bladder. 

Treatment of Severe After-pains. — If the after-pains be very 
severe an opiate may be administered, or if the lochia be not over- 
abundant a linseed-meal poultice sprinkled with laudanum or with the 
chloroform and belladonna liniment may be applied. If proper care 
have been taken to induce uterine contraction, they will seldom be sufB- 
oiently severe to require treatment. In America quinine in doses of ten 
grains twice daily has been strongly recommended, especially when 
opiates fail and when the pains are neuralgic in character; and I have 
found this remedy answer extremely well. The quinine is best given 
in solution with ten or fifteen minims of hydrobromic acid, which 
materially lessens the unpleasant head symptoms often accompanying 
the administration of such large doses. The inhalation of the nitrite 
of amyl in severe cases is said to be very efficacious.^ 

Diet and Reg-imen. — The diet of the puerperal patient claims care- 
ful attention, the more so as old prejudices in this respect are as yet far 
from exploded, and as it is by no means rare to find mothers and nurses 
who still cling tenaciously to the idea that it is essential to prescribe a 
low regimen for many days after labor. The erroneousness of this plan 
is now so thoroughly recognized that it is hardly necessary to argue the 
point. There is, however, a tendency in some to err in the opposite 
direction, which leads them to insist on the patient's consuming solid 
food too soon after delivery, before she has regained her appetite, therebv 
producing nausea and intestinal derangement. Our best guide in this 
matter is the feeling of the patient herself. If, as is often the case, she 
be disinclined to eat, there is no reason why she should be urged to do 
so. A good cup of beef-tea, some bread and milk, or an ^gg beat up 
with milk may generally be given with advantage shortly after deliverv, 
:and many patients are not inclined to take more for the first day or so. 
If the patient be hungry, there is no reason why she should not have 
some more solid but easily digested food, such as white fish, chicken, or 
sweetbread, and after a day or two she may resume her ordinary diet, 
bearing in mind that, being confined to bed, she cannot with advantage 
consume the same amount of solid food as when she is uj) and about. 
Dr. Oldham, in his presidential address to the Obstetrical Society,- has 
some apposite remarks on this point, which are worthy of quotation: 
*^A puerperal month under the guidance of a monthly nurse is easilv 
drawn out, and it is well if a love of the comforts of illness and the 
persuasion of being delicate, which are the infirmities o^ manv women, 
do not induce a feeble life which long survives after the occasion o^ it 
is forgotten. I know no reason why, if a woman is cH>ntined earlv in 
the morning, she should not have her breakfast of tea and toast at nine, 
her luncheon from some digestible meat at one, her cup oi^ tea at five, 
lier dinner with chicken^ at seven, and her tea again at nine, ov the 
equivalent, according to the variation of her hal)its of living. Ot" 

^^rr. F. AV. Kendle, Lamrf. 1SS7. vol. i. p. tUH>. 
'^ ObsM. Tran.s 18GC), vol. vi. p. 14. 



560 THE PUERPERAL STATE. 

course there is the common-sense selection of articles of food^ guard in 2: 
against excess and avoiding stimulants. But gruel and slops and all 
intermediate feeding are to be avoided." Xo one who has seen both 
methods adopted can fail to have been struck with the more rapid and 
satisfactory convalescence which takes place when the patient's strength 
is not weakened by an unnecessarily low diet. Stimulants, as a rule, are 
not required ; but if the patient be weakly and exhausted, or if she be 
accustomed to their use, there can be no reasonable objection to their 
j udicious administration . 

Immediately after delivery a warm napkin is applied to the vulva, 
and after the patient has rested a little the nurse removes the soiled 
linen from the bed and washes the external genitals. It is impossible 
to pay too much attention during the subsequent progress of the case 
to the maintenance of perfect cleanliness. Perfectly antiseptic mid- 
wifery is no doubt an impossibility, but a near approach to it may be 
made, and the greater the care taken the more certainly will the safety 
of the patient be ensured.^ It will be a wise precaution to advise the 
nurse never to touch the genitals for the first few days unless her hands 
have been moistened in a l-in-20 solution of carbolic acid or 1-in-lOOO 
solution of perchloride of mercury, or lubricated with carbolized vase- 
line. The linen should be frequently changed, and all dirty linen and 
discharges immediately removed from the apartment. The vulva should 
be washed daily with a solution of perchloride of mercury of the strength 
of l-in-2000, or with Condy's fluid and water, and the patient will 
derive great comfort from having the vagina syringed gently out once 
a day with the same solution. It is well also to have the vulva thor- 
oughly washed T^'ith corrosive-sublimate lotion at the commencement 
of labor, and the vagina syringed at the same time. The remarkable 
diminution of mortality which has followed such antiseptic precautions 

^ The following rules I have for the past year or two distributed to themonthlv 
nurses attending my own patients, with the result, I believe, of a marked improve- 
ment in their comfort and a more generally satisfactory convalescence : 

ANTISEPTIC EULE? FOR MOXTHLY XURSES. 

L Two bottles are supplied to each patient. One contains a mixture of perchloride 
of mercury of the strength of 1 part to 1000 of water (called the 1-in-lOOO solution), 
the other carbolized vaseline (1 in 81. 

2. A small basin containing the 1-in-lOOO solution must always stand by the bedside 
of the patient, and the nurse must thoroughly rinse her hands in it every time she touches 
the patient in the neighborhood of the genital organs, for washing or any other pur- 
pose whatsoever, before or during labor and for a week after delivery. 

3. All sponges, vaginal and rectal pipes, catheters, etc. must be dipped in the 1-in- 
1000 solution before being used. The surfaces of slippers, bedpans, etc. should also be 
sponged with it. 

4. Vaginal pipes, enema-tubes, catheters, etc. should be smeared with the carbolized 
vaseline before use. 

■5. Unless express directions are given to the contrary, the vagina should be syringed 
twice daily after delivery with the 1-in-lOOO solution," with an equal quantity of hot 
water added to it. 

6. All water used for washing should have sufficient Condy's fluid dropped into it to 
give it a pale pink color. 

7. All soiled linen, diapers, etc. should be immediately removed from the bedroom. 
X.B. — These rules are for the purpose of protecting the patient from the risk arising 

from accidental contamination of the hands, sponges, etc. It is, therefore, hoped that 
they will be faithfully and minutely adhered to. 



THE PUERPERAL STATE AND ITS MANAGEMENT. 561 

in lying-in hospitals well shows the importance of these measures. Tlie 
room should be kept tolerably cool and fresh air freely admitted. 

It is customary, on the morning of the second or third day, to secure 
an action of the bowels ; and there is no better way of doing this than 
by a large enema of soap and water. If the patient object to this and 
the bowels have not acted, some mild aperient may be administered, 
such as a small dose of castor oil, a few grains of colocynth-and-hen- 
bane pill, or the popular French aperient, the " Tamar Indien.'^ 

The management of suckling and of the breasts forms an important 
part of the duties of the monthly nurse which the practitioner shonld 
himself superintend. This will be more conveniently discussed under 
the head of lactation. 

Importance of Prolonged Rest. — The most important part of the 
management of the puerperal state is the securing to the patient pro- 
longed rest in the horizontal position in order to favor proper involu- 
tion of the uterus. For the first few days she should be kept as quiet 
and still as possible, not receiving the visits of any but her nearest rela- 
tives, thus avoiding all chance of undue excitement. It is customary 
among the better classes for the patient to remain in bed for eight or 
ten days, but, provided she be doing well, there can be no objection to 
her lying on the outside of the bed or slipping on to a sofa somewhat 
sooner. After ten days or a fortnight she may be permitted to sit on a 
chair for a little, but I am convinced that the longer she can be per- 
suaded to retain the recumbent position, the more complete and satis- 
factory will be the progress of involution ; and she should not be allowed 
to walk about until the third week, about which time she may also be 
permitted to take a drive. If it be borne in mind that it takes from 
six weeks to two months for the uterus to regain its natural size, the 
reason for prolonged rest will be obvious. The judicious practitioner, 
however, Avhile insisting on this point, will take measures at the same 
time not to allow the patient to lapse into the habits of an invalid or 
to give the necessary rest the semblance of disease. 

Subsequent Treatment. — Toward the termination of the puerperal 
month some slight tonic, such as small doses of quinine with phosphoric 
acid, may be often given with advantage, especially if convalescence be 
tardy. Nothing is so beneficial in restoring the patient to her usual 
health as change of air, and in the upper classes a short visit to the 
seaside may generally be reconnneuded, with the certainty of much 
benefit. 

36 



662 THE PVEBPEBAL STATE. 



CHAPTER II. 

MANAGEMENT OF THE IXFANT, LACTATIOX, ETC. 

Commencenient of Respiration. — Almost immediatelv after its 
expulsion a healthy child cries aloud, thereby showing that respiration 
is established ; and this may be taken as a signal of its safety. The 
first respiratory movements are excited partially by reflex action result- 
ing from the contact of the cold external air with the cutaneous nerves, 
and partly by the direct irritation of the medulla oblongata in conse- 
quence of the circulation through it of blood no longer oxygenated in 
the placenta. 

Apparent Death of the Ne'^born Child. — Xot infrequentlv the 
child is born in an apparently lifeless state. This is especially likely 
to be the case when the second stage of labor has been unduly prolonged, 
so that the head has been subjected to long-continued pressure. The 
utero-placental circulation is also apt to be injuriously interfered with 
before the birth of the child when a tardy labor has produced tonic 
contraction of the uterus and consequent closure of the uterine sinuses, 
or, more rarely, from such causes as the iujudiciotis administration of 
ergot, premature separation of the placenta, or compression of the 
umbilical cord. In any of these cases it is probable that the arrest of 
the utero-placental circulation induces attempts at inspiration which are 
necessarily fruitless, since air cannot reach the lungs, and the foetus may 
die asphyxiated, the existence of the respiratory movement being proved 
on post-mortem examination by the presence in the lungs of liquor amnii, 
mucus, and meconium, and by the extravasation of blood from the rup- 
ture of their engorged vessels. 

In most cases, when the child is born in a state of apparent asphyxia 
its face is swollen and of a dark livid color. It not infrequently makes 
one or two feeble and gasping eiforts at respiration, without any definite 
cry ; on auscultation the heart may be heard to beat Aveakly and slowly. 
Under such circumstances there is a fair hope of its recovery. In other 
cases the child, instead of being turgid and livid in the face, is pale, 
with flaccid limbs and no appreciable cardiac action ; then the prognosis 
is mtich more unfavorable. 

Treatment of Apparent Death. — Xo time should be lost in endeav- 
oring to excite respiration, and at first this must be done by applying 
suitable stimulants to the cutaneous nerves in the hope of exciting 
reflex action. The cord should be at once tied and the child removed 
from the mother, for the final uterine contractions have so completely 
arrested the utero-placental circtilation as to render it no longer of any 
value. If the face be very livid, a few drops of blood may with advan- 
tage be allowed to flow from the cord before it is tied, with the view of 
relieving the embarrassed circtilation. Very often some slight stimulus, 



MANAGEMENT OE THE INFANT, LACTATION, ETC. rjf)^ 

such as one or two sharp slaps on th(3 thorax or rapidly rubbing the 
body with brandy poured into the palms of the hands, will suffice to 
induce respiration. Failing this, nothing acts so well as the sudden and 
instantaneous application of heat and cold. For this purpose extremely 
hot water is placed in one basin, and quite cold water in another. Tak- 
ing the child by the shoulders and legs, it should be dipped for a single 
moment into the hot water, and then into the cold ; and these alternate 
applications may be repeated once or twice as occasion requires. The 
effect of this measure is often very marked, and I have frequently seen 
it succeed when prolonged efforts at artificial respiration have been made 
in vain. 

If these means fail, an endeavor must be at once made to carry 
on respiration artificially. The best means of doing this have been 
exhaustively studied by Dr. Champneys,^ who considers the only two 
reliable means of carrying on artificial respiration are those of Schultze 
and Sylvester. The Sylvester method is, on the whole, that which is 
most easily applied, and on account of the compressibility of the thorax 
it is peculiarly suitable for infants. The child being laid on its back 
with the shoulders slightly elevated and the feet held in an elongated 
position by an assistant, the elbows are grasped by the operator and 
alternately raised above the head and slowly depressed against the sides 
of the thorax, so as to produce the effect of inspiration and expiration. 
If this do not succeed, the Marshall Hall method may be substituted, 
and one or more of the plans of exciting reflex action through the 
cutaneous nerves may be alternated with it. 

Other means of exciting respiration have been recommended. One 
of them, much used abroad, is the artificial insufflation of the lungs bv 
means of a flexible catheter guided into the glottis or by placing a hand- 
kerchief over the child's mouth and directly insufflating the lungs. It 
is not difficult to pass the end of a catheter into the glottis, using the 
little finger as a guide ; and, once in position, it may be used to blow 
air gently into the lungs, which is expelled by compression on the 
thorax, the insufflation being repeated at short intervals of about ten 
seconds. One advantage of this plan is that it allows the liquor amnii 
and other fluids Avhich may have been drawn into the lungs in the pre- 
mature efforts at respiration before birth to be sucked up into the cath- 
eter, and so removed from the lungs. Dr. Chamj)neys recommends 
that when the catheter is passed into the trachea for about three inches 
from the child's mouth, the thorax should be gently com]>ressed, and 
then air should be blown through the catheter. The effect of this 
mano3Uvre is that any mucus or fluid in the tmchea passes upward 
through the glottis into the ])harynx. The same effect mav be ]M\xluced, 
but less ])erfectly, by placing the hand over the nostrils of the child, 
blowing into its mouth, and immediately afterward con\pressing the 
thorax. One of these methods should certainly be tried i(" all other 
means have failed. Faradization along the course of the ]>lnvnie nerves 
is a promising means of^inducMug respiration which should be usihI if 
tlu^ ])roper ap})aratus can be procured. Knconragement to peisevere in 
our endc^avors to resuscitate the child may be il(M-ived tVoin the luimer- 
' M'iHco-C/iir. Tran.^., vol. Ixiv. pp. II, ST. :uul vol. Ixv. \\ 7^. 



564 THE PVERPEBAL STATE. 

ous authenticated instances of success after the lapse of a considerable 
time, even of an hour or more. As long as the cardiac pulsations con- 
tinue, however feebly, there is no reason to despair ; and Champneys 
has collected some apparently authenticated cases in which children 
seemingly dead have been buried for some hours and then dug up 
and restored to life. 

"Washing- and Dressing- of the Child. — AVhen the child cries lus- 
tily from the first, it is customary for the nurse to wash and dress it as 
soon as her immediate attendance on the mother is no longer required. 
For this purpose it is placed in a bath of warm water and carefully 
soa^^ed and sponged from head to foot. AVith the view of facilitating 
the removal of the unctuous material with which it is covered, it is 
usual to anoint it with cold cream or olive oil, which is washed ofP in 
the bath. Xurses are apt to use undue roughness in endeavoring to 
remove every particle of the vernix caseosa, small portions of which 
are often firmly adherent. This mistake should be avoided, as these 
particles will soon dry up and become spontaneously detached. The 
cord is generally wrapped in a small piece of charred linen, which is 
supposed to have some slight antiseptic property, and this is renewed 
from day to day until the cord has withered and separated. This gen- 
erally occurs Avithin a week; and a small pad of soft linen is then 
placed over the umbilicus and supported by a flannel belly-band placed 
around the abdomen, which should not be too tight for fear of embar- 
rassing the respiration. By this means the tendency to umbilical hernia 
is prevented. 

The clothing of the infant varies according to fashion and the cir- 
cumstances of the parents. The important points to bear in mind are 
that it should be warm (since newly-born children are extremely sus- 
ceptible to cold), and at the same time light and sufficiently loose to 
allow free play to the limbs and thorax. All tight bandaging and 
swaddling, such as is so common in some parts of the Continent, should 
be avoided, and the clothes should be fastened by strings or by sewing, 
and no pins used. At the present day it is customary not to use caps, 
so that the head may be kept cool. The utmost possible attention 
shouki be paid to cleanliness, and the child should be regularly bathed 
in tepid water, at first once daily, and after the first few weeks both 
night and morning. After drying, the flexures of the thighs and arms 
and the nates should be dusted with violet powder or fuller's earth to 
prevent chafing of the skin. The excrements should be received in 
napkins wrapped round the hips, and great care is required to change 
the napkins as often as they are wet or soiled, otherwise troublesome 
irritation will arise. A neglect of this precaution and the washing of 
the napkins with coarse soap or soda are among the principal causes of 
the eruptions and excoriations so common in badly-cared-for children. 
AVhen washed and dressed the child may be placed in its cradle and 
covered with soft blankets or an eider-down quilt. 

As soon as the mother has rested a little it is advisable to place the 
child to the breast. This is useful to the mother by favoring uterine 
contraction. Even now there is in the breasts a variable quantity of 
the peculiar fluid known as colostrum. This is a viscid yellowish secre- 



MANAGEMENT OF THE INFANT, LACTATION, ETC. 565 

tion, differeut in appearance from the thin bluish milk which is subse- 
quently formed. Examined under the microscope, it is found to con- 
tain some milk-globules and a number of large granular and small fat- 
corpuscles. It has a purgative property, and soon produces, with less 
irritation than any of the laxatives so generally used, a discharge of the 
meconium with which t\\Q bowels are loaded. Hence the accoucheur 
should prohibit the common practice of administering castor oil or other 
aperient within the first few days after birth, although there can be no 
objection to it in special cases if the bowels appear to act inefficiently 
and with difficulty. 

Over-frequent Suckling* should be Avoided. — For the first few 
days, and until the secretion of milk is thoroughly established, the child 
should be put to the breast at long intervals only. Constant attempts 
at suckling an empty breast lead to nothing but disappointment, both to 
the mother and child, and by unduly irritating the mammse sometimes 
to positive harm. Therefore, for the first day or two it is sufficient if 
the child be applied to the breast twice, or at most three times, in the 
twenty-four hours. Nor is it necessary to be apprehensive, as many 
mothers naturally are, that the child will suffer from want of food. A 
few spoonfuls of milk and water being given from time to time, the 
child may generally wait without injury until the milk is secreted. This 
is usually about the third day, when the secretion is found to be a 
whitish fluid, more watery in appearance than cow's milk, and showing 
under the microscope an abundance of minute spherical globules refract- 
ing light strongly, which are abundant in proportion to the quality of 
the milk. A certain number of granular corpuscles may also be 
observed shortly after the birth of the child, but after the first month 
these should have almost altogether disappeared. The reaction of 
human milk is decidedly alkaline, and the taste much sweeter than 
that of cow's milk. 

The importance to the mother of nursing her own child whenever 
her health permits, on account of the favorable influence of lactation 
in promoting a proper involution of the uterus, has already been 
insisted on. Unless there be some positive contraindication, such as 
a marked striunous cachexia, an hereditary phthisical tendency, or 
great general debility, it is the duty of the accoucheur to urge the 
mother to attempt lactation, even if it be not carried on more tlian a 
month or two. It is, however, the fixct that in the upper classes o^ 
so(!iety a larger number of patients are unable to nurse, even though 
willing and anxious to do so. In some there is hardly any lacteal 
secretion at all ; in others there is at first an over-abundance of watery 
and innutritions milk, which floods the breasts an«l soon dies awav 
altogether. 

When the Mother cannot Nurse, a Wet-nurse should be Pro- 
cured. — Whenever the mother cannot or will not nurse the question 
will arise as to the method of bringing u}> the child. From manv 
causes there is an increasing tendency to resort to bottle-fciHling, instead 
of procuring the services of a wet-nurse, even when the question of 
expense does not eonu^ into consideration. No lon^- experience is 
required (o prove llial hand-feeding is a bad and inq^erteet substitmo 



566 THE PUERPERAL STATE. 

for nature's mode, and one which the practitioner should discourage 
whenever it lies in his power to do so. It is true that in many cases 
bottle-fed children do well, but there is good reason to believe that even 
w^hen apparently most successful the children are not so strong in after 
life as they would have been had they been brought up at the breast. 
AVhen, in addition, it is borne in mind how much of the success of 
hand-feeding depends on intelligent care on the part of the nurse, what 
evils are apt to accrue from the injurious selection of the food and from 
ignorance of the commonest laws of dietetics, there is abundant reason 
for urging the substitution of a wet-nurse whenever the mother is 
unable to undertake the suckling of her child. It must be admitted 
that good hand-feeding is better than bad wet-nursing, and the success 
of the latter hinges on the proper selection of a wet-nurse. As this 
falls within the duties of the practitioner, it will be well to point out 
the qualities which should be sought for in a wet-nurse before proceed- 
ing to discuss the mode of rearing the child at the breast. 

Selection of a Wet-Nurse. — In selecting a wet-nurse we should 
endeavor to choose a strong, healthy woman, who should not be over 
thirty or thirty-five years of age at the outside, since the quality of 
the milk deteriorates in women avIio are more advanced in life. For 
a like inferiority a very young woman of sixteen or seventeen should 
be rejected. It is needless to say that care must be taken to ascertain 
the absence of all traces of constitutional disease, especially marks of 
scrofula or enlarged cervical or inguinal glands, which may possibly be 
due to antecedent syphilitic taint. If the nurse be of good muscular 
development, healthy-looking, wnth a clear complexion, and sound 
teeth (indicating a generally good state of health), the color of the 
hair and eyes, is of secondary importance. It is commonly stated that 
brunettes make better nurses than blondes, but this is by no means 
necessarily the case ; and, provided all the other points be favorable, 
fairness of skin and hair need be no bar to the selection of a nurse. 
The breasts should be pear-shaped, rather firm, as indicating an abun- 
dance of gland-tissue, and with the superficial veins well marked. Large, 
flabby breasts owe much of their size to an undue deposit of fat, and 
are generally unfavorable. The nipple should be prominent, not too 
large, and free from cracks and erosions, which if existing might lead 
to subsequent difficulties in nursing. On pressing the breast the milk 
should flow from it easily in a number of small jets, and some of it 
should be preserved for examination. It should be of a bluish-white 
color, and when placed under the microscope the field should be covered 
with an abundance of milk-corpuscles, and the large granular corpuscles 
of the colostrum should have entirely disappeared. If the latter be 
observed in any quantity in a woman who has been confined five or 
six weeks, the inference is that the milk is inferior in quality. It is 
not often that the practitioner has an opportunity of inquiring into the 
moral qualities of the nurse, although much valuable information might 
be derived from a knowledge of her previous character. An irascible, 
excitable, or highly nervous woman will certainly make a bad nurse, 
and the most trivial causes might afterward interfere with the quality 
of her milk. Particular attention should be paid to the nurse's own 



MANAGEMENT OF THE INFANT, LACTATION, ETC. rjijl 

child, since its condition affords the best criterion of tlie quality of her 
milk. It should be plump, well-nourished, and free from all blemishes. 
If it be at all thin and wizened, especially if there be any snuffling at 
the nose, or should any eruption exist affording the slightest suspicion 
of a syphilitic taint, the nurse should be unhesitatingly rejected. 

The manag-ement of suckling- is much the same whether the child 
is nursed by the mother or by a wet-nurse. As soon as the sup})ly of 
milk is sufficiently established the child must be put to the breast at 
short intervals, at first of about two hours, and in about a month or 
six weeks of three hours. From the first few days it is a matter of 
the greatest importance both to the mother and child to acquire regular 
habits in this respect. If the mother get into the way of allowing the 
infant to take the breast whenever it cries as a means of keeping it 
quiet, her own health must soon suffer, to say nothing of the discom- 
fort of being incessantly tied to the child's side ; while the child itself 
has not sufficient rest to digest its food, and very shortly diarrhoea or 
other dyspeptic symptom is pretty sure to follow. After a month 
or two the infant should be trained to require the breast less often at 
night, so as to enable the mother to have an undistui'bed sleep of six 
or seven hours. For this purpose she should arrange the times of 
nursing so as to give the breast just before she goes to bed, and not 
again until the early morning. If the child should require food in the 
interval, a little milk and water from the bottle may be advantageously 
given. 

The diet of the nursing woman should be arranged on ordinary 
principles of hygiene. It should be abundant, simple, and nutritious, 
but all rich and stimulating articles of food should be avoided. A 
common error in the diet of wet-nurses is over-feeding, which con- 
stantly leads to deterioration of the milk. Many of these women 
before entering on their functions have been liviug on the simplest 
and even sparest diet, and not uncommonly, in the better class of 
houses, they are suddenly given heavy meat meals three and even four 
times a day, and often three or four glasses of stout. It is hardly a 
matter of astonishment that under such circumstances their milk should 
be found to disagree. For a nursing-woman in good health two gooil 
meat meals a day, with two glasses of beer or porter, and as much milk 
and bread-and-butter as she likes to take in the intervals, should be 
amply sufficient. Plenty of moderate exercise should be taken, and 
the more the nurse and child are ouff in the open air, provided the 
weather be reasonably fine, the better it is for both. 

[Usually, the wet-niu'ses employed in oiu' cities are of foreign birth ; 
where they are natives, theii* children are commonly illegitimate. An 
American nurse is in general })referable, and as a rule, those making 
application have not been in the habit of using malt drinks. A 
healthy woman will usually nurse well on her ordinary diet, which 
should be largely farinaceous. Ale is often recommended to nin*sing 
mothers, and so also is tea, but both are very infericn* to milk and 
farinaceous diets pre)>ared with milk. Broma ]>repared with cream I 
have seen taken once a day, for a change, with advantage. — 1m\] 

Sig-ns of Successful Lactation. — Carried on metluHlit'alK- in this 



568 THE PUERPERAL STATE. 

manner, wet-nursing should give but little trouble. In the intervals 
between its meals the child sleeps most Of its time, and wakes with 
regularity to feed ; but if the child be wakeful and restless, cry after 
feeding, have disordered bowels, and, above all, if it do not gain, week 
by week, in weight (a point which should be from time to time ascer- 
tained by the scales), w^e may conclude that there is either some grave 
defect in the management of suckling or that the milk is not agreeing. 
Should this unsatisfactory progress continue in spite of our endeavors 
to remedy it, there is no resource left but the alteration of the diet, 
either by changing the nurse or by bringing up the child by hand. 
The former should be preferred whenever it is practicable, and in the 
upper ranks of life it is by no means rare to have to change the wet- 
nurse two or three times before one is met with whose milk agrees per- 
fectly. If the child have reached six or seven months of age, it may 
be preferable to w^ean it altogether, especially if the mother have nursed 
it, as hand-feeding is much less objectionable if the infant have had the 
breast for even a few months. 

Period of Weaning-. — As a rule, weaning should not be attempted 
until dentition is fairly established, that being the sign that nature has 
prepared the child for an alteration of food ; and it is better that the 
main portion of the diet should be breast-milk until at least six or seven 
teeth have appeared. This is a safer guide than any arbitrary rule taken 
from the age of the child, since the commencement of dentition varies 
much in different cases. About the sixth or seventh month it is a good 
plan to commence the use of some suitable artificial food once a day, so 
as to relieve the strain on the mother or nurse, and prepare the child for 
weaning, which should always be a very gradual process. In this way 
a meal of rusks of entire wheat-flour, or of beef or chicken tea, with 
bread-crumb in it, may be given with advantage ; and as the period 
for weaning arrives a second meal may be added, and so eventually the 
child may be weaned without distress to itself or trouble to the nurse. 

The disorders of lactation are numerous, and as they frequently 
come under the notice of the practitioner, it is necessary to allude to 
some of the most common and important. 

Means of Arresting the Secretion of Milk. — The advice of the 
accoucheur is often required in cases in which it has been determined 
that the patient is not to nurse, w^hen we desire to get rid of the milk 
as soon as possible, or when at the time of weaning the same object is 
sought. The extreme heat and distension of the breasts in the former 
class of cases often gives rise to much distress. A smart saline aperient 
will aid in removing the milk, and for this purpose a double Seidlitz 
powder or frequent small doses of sulphate of magnesia act well, while 
at the same time the patient should be advised to take as small a quan- 
tity of fluid as possible. Iodide of potassium in large doses of twenty 
or twenty- five grains, repeated twice or thrice, has a remarkable effect 
in arresting the secretion of milk. This observation was first empiri- 
cally made by observing that the secretion of milk ^vas arrested when 
this drug was administered for some other cause ; and I have frequently 
found it answer remarkably w^ell. The distension of the breasts is best 
relieved by covering them with a layer of lint or cotton-wool soaked in 



MANAGEMENT OF THE INFANT, LACTATION, ETC. 5G9 

a spirit lotion or eau de Cologne and water, over which oiled silk is 
placed, and by directing the nurse to rub them gently with warm oil 
whenever they get hard and lumpy. Breast-pumps and similar contri- 
vances only irritate the breasts, and do more harm than good. The 
local application of belladonna has been strongly recommended as a 
means for preventing lacteal secretion. As usually applied, in the form 
of belladonna plaster, it is likely to prove hurtful, since the breast often 
enlarges after the plasters are applied, and the pressure of the unyield- 
ing leather on which they are spread produces intense suffering. A 
better way of using it is by rubbing down a drachm of the extract of 
belladonna with an ounce of glycerin, and applying this on lint. In 
some cases it answers extremely well, but it is very uncertain in its 
action, and frequently is quite useless. 

A deficiency of milk in nursing'-niothers is a very common source 
of difficulty. In a wet-nurse this drawback is, of course, an indication 
for changing the nurse ; but to the mother the importance of nursing 
is so great that an endeavor must be made either to increase the flow of 
milk or to supplement it by other food. Unfortunately, little reliance 
€an be placed on any of the so-called galactagogues. The only one 
which in recent times has attracted attention is the leaves of the castor- 
oil plant, which, made into poultices and applied to the breast, are said 
to have a beneficial effect in increasing the flow of milk. More reliance 
must be placed in a sufficiency of nutritious food, especially such as 
contains phosphatic elements : stewed eels, oysters, and other kinds of 
shell-fish, and the Revalenta Arabica, are recommended by Dr. Routh, 
who has paid some attention to this point,^ as peculiarly appropriate. 
If the amount of milk be decidedly deficient, the child should be less 
often applied to the breast, so as to allow milk to collect, and pro])erly 
j)repared cow's milk from a bottle should be given alternate!) with the 
breast. This mixed diet generally answers well, and is far preferable 
to pure hand-feeding. 

[There is no diet equivalent to milk for a nursing-mother, where it 
agrees with her. This I have tested repeatedly in women who had 
failed entirely in former attempts to nurse their infiuits. One lady who 
had lost her milk three times at the end of a month, and had nui*sed 
two babies into starvation, was enabled to nurse her fourth while on a 
milk diet for eighteen months, and gained while doing so nineteen 
pounds. Another gained sixty-five pounds Avhile nursing, and her son 
was very large for his age. A third lost a child by hand-fooding, and 
mu'sed the next infiuit on a milk diet, at the same time becoming fatter 
than she had ever been. A decided advantage in the use of milk is, 
that it prevents the exhausted feeling so common with delicate nui*sing 
mothers. I liave had a patient of 8(3 ])ounds weight use two quarts t>f 
milk a day, and at the same time eat her usual measure of food, which 
had always been ol' small amount. — Kd.] 

Depressed Nipples. — A not uncommon sourci^ o( ditliculty is a 
depressed condition of the nipples, which is generallv produced bv the 
constant pressure oi' the stays. The risult is, that the child, unable to 
grasp the nippK^ and wi^aricnl whh nu^llcctnal ctlorts, mav at last ivt'use 

' Kouth oi\ liihtnt-iWdiiu/. 



570 THE PUERPERAL STATE. 

the breast altogether. An endeavor should be made to elongate the 
nipple before putting it into the child^s mouth, either by the fingers or 
by some form of breast-pump, Avhich here finds a useful application. 
In the worst class of cases, when the nipple is permanently depressed, 
it may be necessary to let the child suck through a glass nipple-shield, 
to which is attached an india-rubber tube similar to that of a sucking- 
bottle ; this it is generally well able to do. 

Fissures and Excoriations of the Nipples. — Fissures and exco- 
riations of the nipples are common causes of suffering, in some cases 
leading to mammary abscess. Whenever the practitioner has the oppor- 
tunity he should advise his patient to prepare the nipple for nursing in 
the latter months of pregnancy; and this may best be done by daily 
bathing it with a spirituous or astringent lotion, such as eau de Cologne 
and water or a weak solution of tannin. After nursing has begun great 
care should be taken to wash and dry the nipple after the child has been 
applied to it, and as long as the mother is in the recumbent position she 
may, if the nipples be at all tender, use zinc nipple-shields with advan- 
tage when she is not nursing. In this way these troublesome complica- 
tions may generally be prevented. The most common forms are either 
an abrasion on the surface of the nipple, which if neglected may form 
a small ulcer, or a crack at some part of the nipple, most generally at 
its base. In either case the suffering when the child is put to the breast 
is intense, sometimes indeed amounting to intolerable anguish, causing 
the mother to look forward with dread to the application of the child. 
Whenever such pain is complained of, the nipple should be carefully 
examined, since the fissure or sore is often so minute as to escape super- 
ficial examination. The remedies recommended are very numerous, 
and not always successful. Amongst those most commonly used are 
astringent applications, such as tannin or Aveak solutions of nitrate of 
silver, or cauterizing the edges of the fissure with solid nitrate of silver, 
or applying the flexible collodion of the Pharmacopoeia. Dr. Wilson 
of Glasgow speaks highly of a lotion composed of ten grains of nitrate 
of lead in an ounce of glycerin, which is to be applied after suckling, 
the nipple being carefully washed before the child is again put to the 
breast. I have myself found nothing answer so well as a lotion com- 
posed of half an ounce of sulphurous acid, half an ounce of the gly- 
cerin of tannin, and an ounce of water, the beneficial effects of which 
are sometimes quite remarkable. Relief may occasionally be obtained 
by inducing the child to suck through a nipple-shield, especially when 
there is only an excoriation ; but this will not always answer, on account 
of the extreme pain which it produces. 

Excessive Flow of Milk. — An excessive flow of milk, known as 
galadorrhcea, often interferes with successful lactation. It is by no 
means rare in the first weeks after delivery for women of delicate con- 
stitution, who are really unfit to nurse, to be flooded with a superabun- 
dance of watery and innutritions milk, which soon produces disordered 
digestion in the child. Under such circumstances the only thing to be 
done is to give up an attempt which is injurious both to the mother and 
child. At a later stage the milk, secreted in large quantities, is suffi- 
ciently nourishing to the child, but the drain on the mother's constitu- 



MANAGEMENT OF THE INFANT, LACTATION, ETC. 571 

tion soon begins to tell on her. Palpitation, giddiness, emaciation, 
headache, loss of sleep, spots before the eyes, indicate the serious effects 
which are being produced, and the absolute necessity of at once stop- 
ping lactation. Whenever, therefore, a nursing-woman suffers from 
such symptoms, it is far better at once to remove the cause, otherwise a 
very serious and permanent deterioration of health might result. When, 
under such circumstances, nursing is unwisely persevered in, most serious 
results may follow. Should any diathetic tendency exist, especially when 
there is a predisposition to phthisis, nothing is so likely to develop it as 
the debility produced by excessive lactation. Certain diseases of the 
eye are then specially apt to occur, such as severe inflanmiation of the 
cornea, leading to opacity and even sloughing, and certain forms of 
choroiditis ; also impairment of accommodation due to defective power 
of the ciliary muscle.^ 

Mammary Abscess. — There is no more troublesome complication 
of lactation than the formation of abscess in the breast — an occurrence 
by no means rare, and which, if improperly treated, may, by long-con- 
tinued suppuration and the formation of numerous sinuses in and about 
the breast, produce very serious effects on the general health. The 
causes of breast abscesses are numerous, and very trivial circumstances 
may occasionally set up inflammation ending in suppuration. Thus it 
may follow exposure to cold, a blow or other injury to the breast, some 
temporary engorgement of the lacteal tubes, or even sudden or depress- 
ing mental emotions. The most frequent cause is irritation from fissures 
or erosions of the nipples, which must therefore always be regarded 
with suspicion and cured as soon as possible. 

The abscess may form in any part of the breast or in the areolar tis- 
sue below it; in the latter case the inflammation very generallv extends 
to the gland-structure. Abscess is usually ushered in by constitutional 
symptoms, varying in severity with the amount of the inflammation. 
Pyrexia is always present, elevated temperature, rapid pulse, and much 
malaise and sense of feverishness, followed in many cases by distinct 
rigor when deep-seated suppuration is taking place. On examining the 
breast it will be found to be generally enlarged and very tender, \\hile 
at the site of the abscess an indurated and painful swelling may be felt. 
If the inflammation be chiefly limited to the subglandular areolar tis- 
sue, there may be no localized sw^elling felt, but the whole breast will 
be acutely sensitive and the slightest movement will cause much ])ain. 
As the case })rogresses the abscess becomes more and more superficial, 
the skin (H)vering it is red and glazed, and if left to itself it bursts. In 
the more serious cases it is by no means rare for nuiltiple abscesses to 
form. These, opening one after the other, lend to the formation of 
numerous fistulous tracts, by whicli the breast may become completelv 
riddled. Shnighing of portii>ns of the gland-tissue may take place, and 
even c{)nsid(M-able hemorrhage from the destruction o\' blood-vessels. 
The general healtii si)on sutfers to a marked cK\oive. and, as the sinuses 
continue^ to su[)piu'ate for many suecissive months, it is bv no means 

' Seo l'\HM-stor of Rroslau in (!r;uMo and Saoiuisch's Ifamiluu-h t!i\< C(\<ain»i(,ii Auinn- 
Iic{lki()i(l(\ and Power on '"Plio Oit^oasos of tlie Kve in Connootioii with Presrnancv." 

Lancet, 18S0, vol. i. p. TOi), ct ^cq. 



0/2 THE PVEBPEEAL STATE. 

uncommon for the patient to be reduced to a state of profound and even 
dangerous debiliU-. 

Treatment. — ^lucli may be done by proper care to prevent the 
formation of abscess, especially by removing engorgement of the lacteal 
ducts, which threatened, by gentle hand-friction in the manner abeady 
indicated. AVhen the general symptoms and the local tenderness indi- 
aite that inflammation has commenced we should at once endeavor to 
moderate it, in the hope that resolution may occur without the forma- 
tion of pus. Here general principles must be attended to, especially 
giving the affected part as much rest as possible. Feverishness mav be 
combated by gentle salines, minute doses of aconite, and large doses of 
quinine, while pain should be relieved by opiates. The patient should 
be strictly confined in bed and the affected breast supported by a sus- 
pensoiy bandage. AVarmth and moisture are the best means of reliev- 
ing the local pain, either in the form of hot fomentations or of light 
poultices of linseed meal or bread and milk, and the breast may be 
smeared with extract of belladonna rubbed down with glycerin, or the 
belladonna liniment sprinkled over the surface of the poultices. The 
local application of ice in india-rubber bag's has been highly extolled 
as a means of relieving the pain and tension, and is said to be much 
more effectual than heat and moisture.^ Generally, the pain and 
irritation produced by putting the child to the breast are so great as to 
contraindicate nm^sing from the affected side altogether, and we must 
trust to relieving tlie tension by poultices, suckling being in the mean 
time carried on by tlie other breast alone. In favorable cases this is 
cpiite possible for a time, and it may be that if the inflammation do not 
end in suppuration, or if the abscess be small and localized, the affected 
breast is again able to resume its functions. Often this is not possible, 
and it may be advisable in severe cases to give up nursing altogether. 

The subsequent management of the case consists in the opening of 
the abscess as soon as the existence of pus is ascertained, either by 
fluctitation, or, if the site of the abscess be deep-seated, by the explor- 
ing-needle. It may be laid down as a principle that tlie sooner the pus 
is evacuated the better, and nothing is to be gained by waiting until it 
is superficial. On the contrary, such delay only leads to more exten- 
sive disorganization of tissue and the fuither spread of inflammation. 

The method of opening the abscess is of primaiy importance. 
It has always been customary simply to open the abscess at its most 
dependent part, withotit using any precaution against the admission of 
air. and afterward to treat secondary abscesses in the same way. The 
results are well known to all practical accoucheurs, and the records of 
surgery fully show how many weeks or months generally elapse in bad 
cases before recovery is complete. The antiseptic treatment of mam- 
mary abscess in the way fii^^^t jwinted out by Lister affords results 
which are of the most remarkable and satisfactory kind. Instead of 
being weeks and months in healing, I believe that the practitioner who 
fairly and minutely carries out Sir Joseph Lister's directions may confi- 
dently look for complete closure of the abscess in a few days ; and I 
know of nothing in tlie whole range of my professional experience that 

^Corson, Amei'. Journ. Obsfet., 1881, vol. xiv. p. 48. 



MANAGEMENT OF THE INFANT, LACTATION, ETC. 573 

has given me more satisfaction than the application of this method to 
abscesses of the breast. The plan I first used is that recommended by 
Lister in the Lancet for 1867, but which is now superseded by his 
improved methods, which of course will be used in preference by all 
who have made themselves familiar with the details of antiseptic sur- 
gery. The former, however, is easily within the reach of every one, 
and is so simple that no special skill or practice is required in its appli- 
cation ; whereas the more perfected antiseptic appliances will probably 
not be so readily obtained and are much more difficult to use. I there- 
fore insert Sir Joseph Lister^s original directions, which he assures me 
are perfectly antiseptic, for the guidance of those who may not be able 
to obtain the more elaborate dressings : "A solution of one part of crys- 
tallized carbolic acid in four parts of boiled linseed oil having been 
prepared, a piece of rag from four to six inches square is dipped into 
the oily mixture and laid upon the skin where the incision is to be 
made. The lower edge of the rag being then raised, while the upper 
edge is kept from slipping by an assistant, a common scalpel or bistoury 
dipped in the oil is plunged into the cavity of the abscess, and an 
opening about three-quarters of an inch in length is made ; and the 
instant the knife is withdrawn the rag is dropped upon the skin as an 
antiseptic curtain, beneath which the pus flows out into a vessel placed 
to receive it. The cavity of the abscess is firmly pressed, so as to force 
out all existing pus as nearly as may be (the old fear of doing mischief 
by rough treatment of the pyogenic membrane being quite ill-founded); 
and if there be much oozing of blood or if there be considerable thick- 
ness of parts between the abscess and the surface, a piece of lint dipped 
in the antiseptic oil is introduced into the incision to check bleeding and 
prevent primary adhesion, which is otherwise very apt to occur. The 
introduction of the lint is effected as rapidly as may be, and under the 
protection of the antiseptic rag. Thus the evacuation of the original 
contents is accomplished with perfect security against the introduction 
of living germs. This, however, would be of no avail unless an anti- 
septic dressing could be applied that would effectually prevent the 
decomposition of the stream of pus constantly flowing out beneath it. 
After numerous disappointments 1 have succeeded with the following, 
whicli may be relied upon as absolutely trustworthy: About six tea- 
spoonfuls of the above-mentioned solution of carbolic acid in linseed 
oil are mixed up with common whiting (carbonate of lime) to the con- 
sistence of a firm paste, which is, in fact, glazier's putty with the addi- 
tion of a little carbolic acid. This is spread upon a piece of common 
tinfoil about six inches square, so as to form a layer about a quarter ot' 
an inch ihick. The tinfoil, thus spread with putty, is placed upon the 
skin so that the middle of it corresponds to the position of the incision, 
the antiseptic rag usetl in optMiing the abscess being removed the instant 
before. The tin is then fixed securely by adlu^sive plaster, the hnvest 
edge being left free for the escape of the discharge into a foUled towel 
l)laced over it and secured by a bandage. The dressing is changed, as 
a gencM-al rule, once in twenty-lbm* hoiu's, but if the abs^vss be a 
very largc^ oui^ i( is prudent to set^ the patient twelve hours after it 
has h(\n\ opened, when, if the towel should bo much stained with 



574 THE PUERPERAL STATE. 

discharge, tlie dressing sliould be changed, to avoid subjecting its 
antiseptic virtues to too severe a test. But after the first twenty- 
four liours a single daily dressing is sufficient. The changing of the 
dressing must be methodically done as follows : A second similar 
piece of tinfoil having been spread with the putty, a piece of rag is 
dipped in the oily solution and placed on the incision the moment 
the first tin is removed. This guards against the possibility of mis- 
chief occurring during the cleansing of the skin with a diy cloth 
and pressing out any discharge which may exist in the cavity. If a 
plug of lint was introduced when the abscess was opened, it is 
removed under cover of the antiseptic rag, which is taken off at the 
moment when the new^ tin is to be applied. The same process is 
continued daily until the sinus closes." 

Treatment of Long-contin led Suppuration. — If the case come 
under our care when the abscess has been long discharging or when 
sinuses have formed, the treatment is directed mainly to procuring a 
cessation of suppuration and closure of the sinuses. For this pur])ose 
methodical strapping of the breast with adhesive plaster, so as to afford 
steady support and compress the opposing pyogenic surfaces, will give 
the best results. It may be necessary to lay open some of the sinuses 
or to inject tinct. iodi or other stimulating lotions, so as to moderate the 
discharge, the subsequent surgical treatment varying according to the 
requirements of each case. In such neglected cases Billroth recom- 
mends that after the patient has been anaesthetized the openings should 
be dilated so as to admit the finger, by which the septa between the 
various sinuses should be broken down and a large single abscess-cavity 
made. This should then be thoroughly irrigated with a 3 per cent, 
solution of carbolic acid, a drainage-tube introduced, and the ordinary 
antiseptic dressings applied. As the drain on the system is great and 
the constitutional debility generally pronounced, much attention must 
be paid to general treatment, and abundance of nourishing food, appro- 
priate stimulants, and such medicines as iron and quinine will be indi- 
cated. 

Hand-feeding". — In a considerable number of cases the inability of 
the mother to nurse the child, her invincible repugnance to a wet-nurse, 
or inability to bear the expense renders hand-feeding essential. It is, 
therefore, of importance that the accoucheur should be thoroughly 
familiar with the best method of bringing up the child by hand, so as 
to be able to direct the process in the way that is most likely to be 
successful. 

Much of the mortality following hand-feeding may be traced to 
unsuitable food. Among the poorer classes especially there is a preva- 
lent notion that milk alone is insufficient, and hence the almost universal 
custom of administering various farinaceous foods, such as corn-flour or 
arrowroot, even from the earliest period. Many of these consist of 
starch alone, and are therefore absolutely unsuited for forming the 
staple of diet on account of the total absence of nitrogenized elements. 
Independently of this, it has been shown that the saliva of infants has 
not the same digestive property on starch that it subsequently acquires, 
and this affords a further explanation of its so constantly producing 



MANAGEMENT OF THE INFANT, LACTATION, ETC. ^jIo 

intestinal derangement. Reason as well as experience abundantly 
proves that the object to be aimed at in hand-feeding is to imitate as 
nearly as possible the food which nature supplies for the newborn 
child, and therefore the obvious course is to use milk from some ani- 
mal, so treated as to make it resemble human milk as nearly as 
may be. 

Of the various milks used, that of the ass, on the whole, most closely 
resembles human milk, containing less casein and butter and more saline 
ingredients. It is not always easy to obtain, and in towns it is excess- 
ively expensive. Moreover, it does not always agree with the child, 
being apt to produce diarrhoea. We can, however, be more certain of 
its being unadulterated, which in large cities is in itself no small 
advantage, and it may be given without the addition of water or 
sugar. 

Goat^s milk in England is still more difficult to obtain, but it often 
succeeds admirably. In many places the infant sucks the teat directly, 
and certainly thrives well on this plan. 

Ccw's Milk, and its Preparation. — In a large majority of cases we 
have to rely on cow's milk alone. It differs from human milk in con- 
taining less water, a larger amount of casein and solid matters, and less 
sugar. Therefore, before being given it requires to be diluted and 
sweetened. A common mistake is over-dilution, and it is far from 
rare for nurses to administer one-third cow's milk to two-thirds water. 
The result of this excessive dilution is that the child becomes pale and 
puny, and has none of the firm and plump appearance of a well-fed 
infant. The practitioner should therefore ascertain that this mistake 
is not being made ; and the necessary dilution will be best obtained by 
adding to pure fresh cow's milk one-third hot w^ater, so as to warm the 
mixture to about 96°, the whole beins; sliolitlv sweetened v>itli suoar 
of milk or ordinary crystallized sugar. After the first two or three 
months the amount of water may be lessened, and pure milk, warmed 
and sweetened, given instead. Whenever it is possible the milk should 
be obtained from the same cow, and in towns some care is requisite to 
see that the animal is properly fed and stabled, Of late years it has 
been customary to obviate the difficulties of obtaining gotxl fresh milk 
by using some of the tinned milks now so easilv to be had. These are 
already sweetened, and sometimes answer well if not given in too weak 
a dilution. One great drawback in bottle-feeding is the tendency of 
the milk to become acid, and hence to produce diarrhiva. This mav be 
obviated to a great extent by adding a tablespoonful of lime-water to 
each bottle, instead of an equal (]uantity of water. 

Artificial Human Milk. — An admirable plan of treating cow's milk, 
so as to reduci^ it to almost absolute chemical identity with human milk, 
has b(HMi devised by Professor Frank land, to whom I am indebttnl for 
permission to insert the recipe. 1 have followed this methixl in nianv 
cases, and find it far superior to the usual one, as it produces an exact 
and uniform compound.. With a little practice nurses can eMq)lov it 
with no more trouble than the ordinary mixino; o\' cow's milk with 
water and sugar. The following extract ivom Or. I'rankland's work^ 
' l-'ninkhuul's Erprriiiuntal lu-.^iarcfus in Chc»u,<(,-i/. p. Slo. 



576 THE PUERPERAL STATE. 

will explain the principles on which the preparation of the artificial 
human milk is founded : " The rearing of infants who cannot be sup- 
plied with their natural food is notoriously difficult and uncertain, 
owing chiefly to the great difference in the chemical composition of 
human milk and cow's milk. The latter is much richer in casein and 
poorer in milk-sugar than the former, whilst ass's milk, which is some- 
times used for feeding infants, is too poor in casein and butter, although 
the proportion of sugar is nearly the same as in human milk. The 
relations of the three kinds of milk to each other are clearly seen from 
the following analytical numbers which express the percentage amounts 
of the different constituents : 

Woman. Ass. Cow. 

Casein 2.7 1.7 4.2 

Butter 8.5 1.3 3.8 

Milk-sugar 5.0 4.5 3.8 

Salts 2 .5 .7 

These numbers show that by the removal of one-third of the casein 
from cow's milk and the addition of about one-third more milk-sugar 
a liquid is obtained which closely approaches human milk in composi- 
tion, the percentage amounts of the four chief constituents being as 
follows : 

Casein 2.8 

Butter 3.8 

Milk-sugar 5.0 

Salts 7 

The following is the mode of preparing the milk : Allow one-third of 
a pint of new milk to stand for about tAvelve hours, remove the cream, 
and add to it two-thirds of a pint of new milk, as fresh from the cow 
as possible. Into the one-third of a pint of blue milk left after the 
abstraction of the cream put a piece of rennet about one inch square. 
Set the vessel in warm water until the milk is fully curdled, an opera- 
tion requiring from five to fifteen minutes according to the activity of 
the rennet, which should be removed as soon as the curding commences 
and put into an egg-cup for use on subsequent occasions, as it may be 
employed daily for a month or two. Break up the curd repeatedly and 
carefully separate the whole of the whey, which should then be rapidly 
heated to boiling in a small tin pan placed over a spirit or gas lamp. 
During the heating a further quantity of casein, technically called 
' fleetings,' separates, and must be removed by straining through mus- 
lin. Now dissolve 110 grains of powdered sugar of milk in the hot 
whey, and mix it with the two-thirds of a pint of new milk to which 
the cream from the other third of a pint was added as already described. 
The artificial milk should be used within twelve hours of its prepara- 
tion ; and it is almost needless to add that all the vessels employed 
in its manufacture and administration should be kept scrupulously 
clean." 1 

^ The following recipe yields the same results, but the method is easier, and I find 
that nurses prepare the milk Avith less difficulty when it is followed : "Heat half a pint 
of skimmed milk to about 96°, that is, just warm, and well stir into the warm milk a 



MANAGEMENT OE THE INFANT, LACTATION, ETC. 577 

Method of Hand-feeding-. — Much of the success of bottle-feeding 
must depend on minute care and scrupulous cleanliness, points whi^h 
cannot be too strongly insisted on. Particular attention should be paid 
to preparing the food fresh for every meal, and to keeping the feeding 
bottle and tubes constantly in water when not in use, so that minute 
particles of milk may not remain about them and become sour. A 
neglect of this is one of the most fertile sources of the thrush from 
which bottle-fed infants often suffer. The particular form of bottle 
used is not of much consequence. Those now commonly employed, 
with a long india-rubber tube attached, are preferable to the older 
forms of fiat bottle, as they necessitate strong suction on the part of * 
the infant, thus forcing it to swallow the food more slowly. Care must 
be taken to give the meals at stated periods, as in breast-feeding, and 
these should be at first about two hours apart, the intervals being 
gradually extended. The nurse should be strictly cautioned against 
the common practice of placing the bottle beside the infant in its 
cradle and allowing it to suck to repletion — a practice which leads to 
over-distension of the stomach and consequent dyspepsia. The child 
should be raised in the arms at the proper time, have its food adminis- 
tered, and then be replaced in the cradle to sleep. In the first few 
weeks of bottle-feeding constipation is very common, and may be 
effectually remedied by placing in the bottle two or three times in the 
twenty-four hours as much phosphate of soda as will lie on a three- 
penny-piece. 

Other Kinds of Pood. — If this system succeed, no other food should 
be given until the child is six or seven months old, and then some of 
the various infants^ foods may be cautiously commenced. Of these 
there are an immense number in common use, some of which are good 
articles of diet, others are unfitted for infants. In selecting them we 
have to see that they contain the essential elements of nutrition in 
proper combination. All those, therefore, that are purely starchy in 
character, such as arrowroot, corn flour, and the like, should be avoided, 
while those that contain nitrogenous as wtII as starch elements may be 
safely given. Of the latter the entire wheat-flour, which contains the 
husks ground down with the wheat, generally answers admirably ; and 
of the same character are rusks, tops and bottoms, Nestle's or Liebig's 
infants' food, and many others. If the child be pale and flabby, some 
more pui'cly animal food may often be given twice a day, and groat 
benefit may be derived from a single meal of beef- chicken- or veal- 
tea, with a little bread-crumb in it, especially after the sixth or seventh 
month. Milk, however, should still form the main article of diet, and 
should continue to do so for many months. 

Management when Milk Disagrees. — If the child be pale, tlabl\v, 
and do not gain flesh, more especially it diarrluva or other intestinal 
disturbance be present, we may be certain that hand-feeding is not 

meiisuve full of WaUlon's extract of reunot. When it is set, break up the eurii quite 
small, and let it stand Cor ten (n-*til'teen minutes, when tlie curd will sink : then plaiv 
the whey in a saueepan and boil quiekly. When quite cold, add two-thirds ot" a funl 
of new milk and twt) teas}>oonfuls o( eream. ^Yell stirriuii" the whole together. If vlur- 
ing the lirst month tlie milk is too rich, use rather more than a tliird of a pint oi whey.' 
37 



578 THE PUERPERAL STATE. 

answering satisfactorily, and that some change is required. If the child 
be not too old, and ^yill still take the breast, that is certainly the best 
remedy, but if that be not possible it is necessary to alter the diet. 
When milk disagrees, cream, in the proportion of one tablespoonful to 
three of water, sometimes answers as well. Occasionally also Liebig's 
or Mellin's infants' food, when carefully prepared, renders good service. 
Too often, however, when once diarrhoea or other intestinal disturbance 
has set in, all our efforts may prove unavailing, and the health, if not 
the life, of the infant becomes seriously imperilled. It is not, however, 
within the scope of this work to treat of the disorders of infants at the 
breast, the proper consideration of which requires a large amount of 
space, and I therefore refrain from making any further remarks on the 
subject. 



CHAPTER III. 

PUEKPEEAL ECLAMPSIA. 

By the term puerperal eclampsia is meant a peculiar kind of epi- 
leptiform convulsions which may occur in the latter months of preg- 
nancy or during or after parturition, and it constitutes one of the most 
formidable diseases with which the obstetrician has to cope. The 
attack is often so sudden and unexpected, so terrible in its nature, and 
attended with such serious danger both to the mother and child, that 
the disease has attracted much attention. 

Its Doubtful Etiolog-y. — The researches of Lever, Braun, Frerichs, 
and many other writers who have shown the frequent association of 
eclampsia with albuminuria, have of late years been supposed to clear 
up to a great extent the etiology of the disease and to prove its depend- 
ence on the retention of urinary elements in the blood. While the 
urinary origin of eclampsia has been pretty generally accepted, more 
recent observations have tended to throw doubt on its essential depend- 
ence on this cause, so that it can hardly be said that we are yet in a 
position to explain its true pathology with certainty. These points will 
require separate discussion, but it is first necessary to describe the cha- 
racter and history of the attack. 

Considerable confusion exists in the description of puerperal convul- 
sions from the coufounding of several essentially distinct diseases under 
the same name. Thus in most obstetric works it has been customary 
to describe three distinct classes of convulsion — the epileptic, the hyster- 
ical, and the apoplectic. The two latter, however, come under a totally 
different category. A pregnant woman may suffer from hysterical par- 
oxysms, or she may be attacked with apoplexy accompanied with coma 
and followed by paralysis. But these conditions in the pregnant or 



PUFAiPERAL ECLAMPSIA. 579 

parturient woman are identical with the same diseases in the non-preg- 
nant, and are in no way special in their nature. True eclampsia, how- 
ever, is different in its clinical history from epilepsy, although the })ar- 
oxysms while they last are essentially the same as those of an ordinary 
epileptic fit. 

Premonitory Symptoms. — An attack of eclampsia seldom occurs 
without having been preceded by certain more or less well-marked pre- 
cursory symptoms. It is true that in a considerable number of cases 
these are so slight as not to attract attention, and suspicion is not aroused 
until the patient is seized with convulsions. Still, subsequent investi- 
gations will very generally show that some symptoms did exist, which 
if observed and properly interpreted might have put the practitioner 
on his guard, and possibly have enabled him to ward off the attack. 
Hence a knowledge of them is of real j^ractical value. The most com- 
mon are associated with the cerebrum, such as severe headache, which 
is the one most generally observed, and is sometimes limited to one side 
of the head. Transient attacks of giddiness, spots before the eyes, loss 
of sight, or impairment of the intellectual faculties are also not uncom- 
mon. These signs in a pregnant woman are of the gravest import, and 
should at once call for investigation into the nature of the case. Less- 
marked indications sometimes exist in the form of irritability, slight 
headache or stupor, and a general feeling of indisposition. Another 
important premonitory sign is oedema of the subcutaneous cellular tis- 
sue, especially of the face or upper extremities, which should at once 
lead to an examination of the urine. 

Whether such indications have preceded an attack or not, as soon as 
the convulsion comes on there can no longer be any doubt as to the 
nature of the case. The attack is generally sudden in its onset, and in 
its character is precisely that of a severe epileptic fit or of the convul- 
sions in children. Close observation shows that there is at first a short 
period of tonic spasm affecting the entire muscular system. This is 
almost immediately succeeded by violent clonic contractions, generally 
commencing in the muscles of the fice, which twitch violently ; the 
expression is horribly altered, the globes of the eyes are turned up under 
the eyelids, so as to leave only the white sclerotics visible ; and the 
angles of the mouth are retracted and fixed in a convulsive grin. The 
tongue is at the same time protruded forcibly, and if care be not taken 
is apt to be lacerated by the violent grinding of the teeth. The face, 
at first pale, soon becomes livid and cyaiiosed, while the veins of the 
neck are distended and the carotids beat vigorously. Frothy saliva 
collects about the mouth, and the whole a[>})earance is so changed as to 
render the ])atient (]uite unrecognizable. The convulsive movements 
soon attack the muscles of the body. The hands and arms, at tii-st rig- 
idly fixed with the thumbs clenched into the palms, begin to jerk, and 
the whole muscular system is thrown into rapidly-recurring convulsive 
spasms. It is evident that the involuntary muscles are implicated in 
the convulsive action as \vell as the voluntary. This is sliown by a 
tem])orary arrest of respiration at the conunencemeiu ot' the attack, fol- 
lowed by irregular nnd hurried respiratory movements pi\Hhicing a 
peculiar hissing sound. The occasional involuntary i^xpulsion o( lu'ine 



580 THE PUERPERAL STATE. 

and feces indicates the same fact. During the attack the patient is 
absolutely unconscious, sensibility is totally suspended, and she has 
afterward no recollection of what has taken place. Fortunately, the 
convulsion is not of long duration, and at the outside does not last more 
than three or four minutes, generally not so long; and it has been 
pointed out that a longer paroxysm would almost necessarily prove fatal 
on account of the implication of the respiratory muscles. In most cases, 
after an interval there is a recurrence of the convulsion characterized by 
the same phenomena, and the paroxysms are repeated with more or less 
force and frequency according to the severity of the attack. Sometimes 
several hours may elapse before a second convulsion comes on ; at others 
the attacks may recur very often, with only a few minutes between 
them. In the slighter forms of eclampsia there may not be more than 
two or three paroxysms in all ; in the more serious as many as fifty or 
sixty have been recorded. 

Condition between the Attacks. — After the first attack the patient 
generally soon recovers her consciousness, being somewhat dazed and 
somnolent, wdth no clear conception of what has occurred. If the 
paroxysms be frequently repeated, more or less profound coma con- 
tinues in the intervals between them, which no doubt depends upon 
intense cerebral congestion, resulting from the interference with the 
circulation in the great veins of the neck, produced by spasmodic con- 
traction of the muscles. The coma is rarely complete, the patient 
showing signs of sensibility when irritated, and groaning during the 
uterine contractions. In the worst class of cases the torpor may become 
intense and continuous, and in this state the patient may die. When 
the convulsions have entirely stopped, and the patient has completely 
regained her consciousness and is apparently convalescent, recollection 
of what has taken place during and some time before the attack may 
be entirely lost ; and this condition may last for a considerable time. 
A curious instance of this once came under my notice in a lady who 
had lost her brother, to whom she was greatly attached, in the week 
immediately preceding her confinement, and in whom the mental dis- 
tress seemed to have had a great deal to do in determining the attack. 
It was many weeks before she recovered her memory, and during that 
time she recollected nothing about the circumstances connected with her 
brother's death, the whole of that week being, as it were, blotted out of 
her recollection. 

Relation of the Attacks to Labor. — If the convulsions come on. 
during pregnancy, we may look upon the advent of labor as almost a 
certainty; and, if we consider the severe nervous shock and general 
disturbance, this is the result we might reasonably anticipate. If they 
occur, as is not uncommon, for the first time during labor, the pains 
generally continue Avith increased force and frequency, since the uterus 
partakes of the convulsive action. It has not rarely happened that the 
pains have gone on with such intensity that the child has been born 
quite unexpectedly, the attention of the practitioner being taken up 
with the patient. In many cases the advent of fresh paroxysms is 
associated with the commencement of a pain, the irritation of which 
seems sufficient to bring on the convulsion. 



PUERPERAL ECLAMPSIA. 581 

Results to the Mother and Child. — The results of eclampsia vary 
according to the severity of the paroxysms. It is generally said tliat 
about one in three or four cases dies. The mortality has certairdy 
lessened of late years, probably in consequence of improved knowledge 
of the nature of the disease and more rational modes of treatment. 
This is well shown by Barker/ who found in 1885 a mortality of 32 
per cent, in cases occurring before and during labor, and 22 per cent. 
in those after labor, while since that date the mortality has fallen to 14 
per cent. The same conclusion is arrived at by Dr. Phillips/ who has 
shown that the mortality has greatly lessened since the practice of 
repeated and indiscriminate bleeding, long considered the sheet-anchor 
in the disease, has been discontinued and the administration of chloro- 
form substituted. 

Cause of Death. — Death may occur daring the paroxysm, and then 
it may be due to the long continuance of the tonic spasm producing 
asphyxia. It is certain that as long as the tonic spasm lasts the respi- 
ration is suspended, just as in the convulsive disease of children known 
as laryngismus stridulus ; and it is possible also that the heart may share 
in the convulsive contraction which is known to affect other involuntary 
nuiscles. More frequently, death happens at a later period from the 
combined effects of exhaustion and asphyxia. The records of post- 
mortem examinations are not numerous ; in those we possess the prin- 
cipal changes have been an anaemic condition of the brain Avith some 
cedematous infiltration. In a few rare cases the convulsions have 
resulted in effusion of blood into the ventricles or at the base of the 
brain. The prognosis as regards the child is also serious. Out of 36 
children. Hall Davis found 26 born alive, 10 being stillborn. There 
is good reason to believe that the convulsion may attack the child in 
utero — of this several examples are mentioned by Cazeaux — or it may 
be subsequently attacked with convulsions, even when apparently 
healthy at birth. 

Pathology. — The precise pathology of eclampsia cannot be con- 
sidered by any means satisfactorily settled. When, in the year 1843, 
Lever first showed that the urine in patients suffering from puerperal 
convulsions was generally highly charged with albumen — a fiict which 
subsequent experience has amply confirmed — it was thought that a key 
to the etiology of the disease had been found. It was known that 
chronic forms of Bright's disease were frequently associate<l with 
retention of uriuar}^ elements in the blood, and not rarely accom- 
panied by convulsions. The natural inference was drawn that the 
convulsions of eclampsia were also due to toxaemia resulting from the 
retention of un^a in tiie blood, just as in the uraMuia of chronic Bright's 
disease; ami this view was a(h)})ted and supported by the authoritv of 
Braun, Prerichs, and many other writers of eminence, and was pretty 
generally received as a satisfactory explanation of the facts. Pivrichs 
modified it so far that he held that the true toxic eloincni was mn iiroa 
as such, but carbonate of ammonia residting tVom its decomposition ; ami 
experiments were made to })rove that the injection of this substance into 
the veins of the lower animals produced convidsions ot' {nvciselv the 

' 2Vie Puerperal DL^eaxe,^, p. l'2o. -' Gtii/\< llospiuil R<porL<, 1S70. 



582 THE PUEEPEBAL STATE. 

same character as eclampsia. Dr. Hammond^ of ^larvland subsequent- 
ly made a series of eounter-experimems, which were held as proving 
that there was no reason to believe that urea ever did become decom- 
posed in the blood in the way that Frerichs supposed, or that the symp- 
toms of ui'semia were ever produced in this way. Others have believed 
that the poisonous elements retained in the blood are not urea or the 
products of its decomposition, but other extractive matters which have 
escaped detection. As time elapsed evidence accumulated to show that 
the relation between albuminuria and eclampsia was not so universal 
as was supposed, or at least that some other factors were necessary to 
explain many of the cases. Numerous cases were observed in which 
albumen was detected in large quantities ^vithout any convulsion fol- 
lowing, and that not only in women who had been the subject of 
Bright's disease before conception, but also when the albuminuria was 
known to have developed during pregnancy. Thus, Imbert-Goubeyre 
found that out of 164 cases of the latter kind, 95 had no eclampsia; 
and Blot, out of 41 cases, found that 34 were delivered without 
untoward symptoms. It may be taken as proved, therefore, that albu- 
minuria is by no means necessarily accompanied by eclampsia. Cases 
were also observed in which the albumen only appeared after the con- 
vulsion ; and in these it was evident that the retention of urinary 
elements could not have been the cause of the attack, and it is highly 
probable that in them the albuminuria was produced by the same cause 
which induced the convulsion. Special attention has been c-alled to this 
class of cases by Braxton Hicks,- who has recorded a considerable num- 
ber of them. He says that the nearly simultaneous appearance of albu- 
minuria and convtilsion — and it is admitted that the two are almost inva- 
riably combined — must then be explained in one of three ways : 

1st. That the convttlsions are the cause of the nephritis. 

2dly. That the convulsions and the nephritis are produced by the 
same cause — e. g. some detrimental ingredient circulating in the blood, 
irritating both the cereljro-spinal system and other organs at the same 
time. 

3dly. That the highly congested state of the venous system induced 
by the spasm of the glottis in eclampsia is able to produce the kidney 
complication. 

More recently. Traiibe and Rosenstein have advanced a theory of 
eclampsia purporting to explain the anomalies. They refer the occtu- 
rence of eclampsia to acute cerebral anaemia resulting from changes in 
the blood incident to pregnancy. The primary factor is the hydremic 
condition of the blood, which is an ordinary concomitant of pregnancy, 
and of coui^se when there is also albuminuria the wateiy condition of 
the blood is greatly intensified ; hence the frequent association of the 
two states. Accompanying this condition of the blood there is increased 
tension of the arterial system, which is favored by the hypertrophy of 
the heart which is known to be a normal occurrence in pregnancy. The 
result of these combined states is a temporary hypersemia of the brain, 
which is mpidly succeeded by serous effusion into the cerebral tissues, 
resulting in pressure on its minute vessels and consequent anaemia. 

^ Amer. Journ. of Med. S:i., 1S61. * Obstet. Tram., 1867, vol. viii. p. 382. 



PUERPERAL ECLAMPSIA. 583 

There is much in this theory that accords with the most recent views as 
to the etiology of convulsive disease; as, for example, the researches of 
Kussmaul and Tenner, who had experimentally proved the dependence 
of convulsion on cerebral anaemia, and of Brown-Sequard, who showed 
that an anaemic condition of the nerve-centres preceded an epileptic 
attack. It explains also very satisfactorily how the occurrence of labor 
should intensify the convulsions, since during the acme of the pains the 
tension of the cerebral arterial system is necessarily greatly increased. 
There are, however, obvious difficulties against its general acceptance. 
For example, it does not satisfactorily account for those cases which are 
preceded by well-marked precursory symptoms, and in which an 
abundance of albumen is present in the urine. Here the premonitory 
signs are precisely those which precede the develojjment of uraemia in 
clu'onic Bright's disease, the dependence of which on the retention in 
the blood of urinary elements can hardly be doubted. Moreover, it 
has been shown by Lohlein and others that on post-mortem examina- 
tion the brain does not, as a rule, exhibit the oedema, anaemia, and flat- 
tened convolutions which this theory assumes. 

MacDonald' has published an interesting paper on this subject, in 
which he describes two very careful post-mortem examinations. lu 
these he found extreme anaemia of the cerebro-spinal centres, w^ith con- 
gestion of the meninges, but no evidence of oedema. He inclines to 
the belief that eclampsia is caused by irritation of the vaso-motor centre 
in consequence of an anaemic condition of the blood produced by the 
retention in it of excrementitious matters which the kidneys ought to 
have removed, this over-stimulation resulting in anaemia of the deeper- 
seated nerve-centres and consequent convulsion. 

Excitability of Nervous System in Puerperal Women as Pre- 
disposing- to Convulsions. — The key to the liability of the puerperal 
woman to convulsive attacks is no doubt to be found in the peculiar 
excitable condition of the nervous system in pregnancy — a fact which 
was clearly pointed out by the late Dr. Tyler Smith and by manv other 
writers. Her nervous system is, in this respect, not unlike that of 
children, in whom the predominant influence and great excitability of 
the nervous system are well-established facts, and in whom preciselv 
similar convulsive seizures are of common occurrence on the application 
of a sufficiently exciting cause. 

Exciting- Causes. — Admitting this, we require some cause to sot the 
predisposed nervous system into morbid action ; and this we may have 
either in a toxieinic or in an extremely watery condition of the bUxHl, 
associated with albuminuria, or along with these, or sometimes inde- 
pendently of them, in some excitement, such as strong emotional dis- 
turbance. It is highly probable, however, that extreme an:emi:i is oiu^ 
of the actual conditions of the nerye-centres — a fact of nuich practical 
importance in reference to treatment. 

Treatment. — The management of cases in which the occunvnce o( 
suspicious symptoms has led to the detection of albuminuria has 
already been fully discussed (p. iM 0. We shall therefore here only 

'See his voluiuo of colloctod ossavs. ou(iiK\l Heart Di-nas-: dtirinq Pro/nanaj, Lou- 
don, 1878. ' ... 



584 THE PUERPERAL STATE. 

consider the treatment of cases in which convulsions have actually 
occurred. 

Until quite recently venesection was regarded as the sheet-anchor 
in the treatment, and blood was always removed copiously, and, there 
is sufficient reason to believe, with occasional remarkable benefit. Many 
cases are recorded in which a patient in apparently profound coma rap- 
idly regained her consciousness when blood was extracted in sufficient 
quantity. The improvement, however, was often transient, the convul- 
sions subsequently recurring with increased vigor. There are good the- 
oretical grounds for believing that bloodletting can only be of merely 
temporary use, and may even increase the tendency to convulsion. 
These are so well put by Schroeder that I cannot do better than quote 
his observations on this point. ''If,'' he says, ''the theory of Traiibe 
and Rosenstein be correct, a sudden depletion of the vascular system, by 
w^hich the pressure is diminished, must stop the attacks. From experi- 
ence it is known that after venesection the quantity of blood soon becomes 
the same through the serum taken from all the tissues, while the qual- 
ity is greatly deteriorated by the abstraction of blood. A short time 
after venesection we shall expect to find the former blood-pressure in 
the arterial system, but the blood far more watery than previously. 
From this theoretical consideration it follows that abstraction of blood, 
if the above-mentioned conditions really cause convulsions, must be 
attended by an immediate favorable result, and under certain circum- 
stances the whole disease may surely be cut short by it. But if all 
other conditions remain the same the blood-pressure will after some time 
again reach its former height. The quality of blood has in the mean 
time been greatly deteriorated, and consequently the danger of the dis- 
ease will be increased." 

These views sufficiently well explain the varying opinions held with 
regard to this remedy, and enable us to understand why, while the eflPects 
of venesection have been so lauded by certain authors, the mortality 
has admittedly been much lessened since its indiscriminate use has been 
abandoned. It does not follow because a remedy, when carried to 
excess, is apt to be hurtful that it should be discarded altogether; 
and I have no doubt that in properly-selected cases and judiciously 
employed venesection is a valuable aid in the treatment of eclampsia, 
and that it is specially likely to be useful in mitigating the first vio- 
lence of the attack and in giving time for other remedies to come into 
action. Care should, however, be taken to select the cases properly, 
and it will be specially indicated when there is marked evidence of 
great cerebral congestion and vascular tension, such as a livid face, a 
full bounding pulse, and strong pulsation in the carotids. The general 
constitution of the patient may also serve as a guide in determining its 
use, and we shall be the more disposed to resort to it if the patient be 
a strong and healthy woman, while, on the other hand, if she be feeble 
and w^eak, we may wisely discard it and trust entirely to other means. 
In any case it must be looked upon as a temporary expedient only, use- 
ful in warding off immediate danger to the cerebral tissues, but never 
as the main agent in treatment. Xor can it be permissible to bleed in 
the heroic manner frequently recommended. A single bleeding, the 



PUERPERAL ECLAMPSIA. 585 

amount regulated by the effect produced^ is all that is ever likely to be 
of service. 

As a temporary expedient, having the same object in view, compres- 
sion of the carotids during the paroxysms is worthy of trial. This was 
proposed by Trousseau in the eclampsia of infants, and in the single 
€ase of eclampsia in which I have tried it it seemed to be decidedly 
beneficial. It is a simple measure, and it offers the advantage of not 
leading to any permanent deterioration of the blood, as in venesection. 

As a subsidiary means of diminishing vascular tension the adminis- 
tration of a strong purgative is desirable, and has the further effect of 
removing any irritant matter that may be lodged in the intestinal tract. 
If the patient be conscious, a full dose of the compound jalap powder 
may be given or a few grains of calomel combined with jalap ; and if 
she be comatose and unable to swallow, a drop of croton oil or a quar- 
ter of a grain of elaterium may be placed on the back of the tongue. 

The great indication in the management of eclampsia is the control- 
ling of convulsive action by means of sedatives. Foremost amongst 
them must be placed the inhalation of chloroform, a remedy which is 
frequently remarkably useful, and which has the advantage of being 
applicable at all stages of the disease and whether the patient be coma- 
tose or not. Theoretical objections have been raised against its employ- 
ment, as being likely to increase cerebral congestion. Of this there is 
DO satisfactory proof; on the contrary, there is reason to think that 
chloroform inhalation has rather the effect of lessening arterial tension, 
while it certainly controls the violent muscular action by which the 
hypersemia is so much increased. Practically, no one who has used it 
can doubt its great value in diminishing the force and frequency of the 
convulsive paroxysms. Statistically, its usefulness is shown by Char- 
pentier in his thesis on the effects of various methods of treatment in 
eclampsia, since out of 63 cases in which it was used, in 48 it had the 
effect of diminishing or arresting the attacks, 1 only proving fatal. 
The mode of administration has varied. Some have given it almost con- 
tinuously, keeping the patient in a more or h^ss profound state of anaes- 
thesia. Others have contented themselves with carefully watching the 
patient, and exhibiting the chloroform as soon as there were any indica- 
tions of a recurring paroxysm, with the view of controlling its inten- 
sity. The latter is the plan I have myself adopted, and of the value 
of which in most cases I have no doubt. Every now and again cases 
Avill occur in which chloroform inhahition is insuthcient to control the 
paroxysm, or in which, from the very cyanosed state of the ])atient, its 
administration seems contraindicated. Moreover, it is advisable to 
have, if possible, some remedy more continuous in its actitMi and 
requiring less constant personal suj)ervision. I..atterly, {\w internal 
administration of chloral has been recommended for this pur[)ose. Mv 
own experience is decidedly in its favor, and I have used, as 1 believe, 
with marked advantage a combination of ehh>i"al with bromide of potas- 
sium, in tlie proportion of twenty grains ot the tornier io half a di-aehm 
of the latter, repeated at' intervals ol' iVoiu tbiu- io six hours. It' the 
})atient be unable to swallow, the chloral may be given in an enema or 
hypodermically, six grains being diluted in oj ot' water and injivttxl 



586 TEE PVEBPERAL STATE. 

UDder the skin. The rejuarkable influence of bromide of potassium in 
controlling the eclampsia of infants would seem to be an indication for 
its use in puerperal cases. Fordyce Baker is opposed to the use of 
chloral, which he thinks excites instead of lessening reflex irritability.^ 
Another remedy, not entirely free from theoretical objections, but 
strongly recommended, is the subcutaneous injection of morphia, which 
has the advantage of being applicable when the patient is quite imable 
to swallow. It may be given in doses of one-third of a grain, repeated 
in a few hours, so as to keep the patient well under its influence. It 
is to be remembered that the object is to control muscular action, so as 
to prevent as much as possible the violent convulsive paroxysm, and 
therefore it is necessary that the narcosis, however produced, should be 
continuous. It is rational, therefore, to combine the intermittent action 
of chloroform with the more continuous action of other remedies, so 
that the former should supplement the latter when insufficient. Inha- 
lation of the nitrite of amyl has been recommended on ^physiological 
grounds as likely to be useful, and is well worthy of trial ; but of its 
action I have as yet no personal experience. Several very successful 
cases of treatment by the inhalation of oxygen have been recorded by 
Schmidt of St. Petersburg.- Pilocarpine has recently been tried, in the 
hope that the diaphoresis and salivation it produces might diminish, 
arterial tension and free the blood of toxic matters. Braun^ admin- 
istered 3 centigrammes of the muriate of pilocarpine hypodermically, 
and reports favorably of the result ; Fordyce Barkei',^ however, is of 
opinion that it produces so much depression as to be dangerous. 

Other remedies, supposed to act in the way of antidotes to urtemic 
poisoning, have been advised, such as acetic or benzoic acid, but they 
are far too uncertain to have any reliance placed on them, and they 
distract attention from more useful measures. 

Precautions during- the Paroxysm. — Precatitions are necessary 
during the fits to prevent the patient injuring herself, especially to 
obviate laceration of the tongue; the latter can be best done by 
placing something between the teeth as the paroxysm comes on, suck 
as the handle of a teaspoon enveloped in several folds of flannel. 

Obstetric Management. — The obstetric management of eclampsia 
will naturally give rise to much anxiety, and on this point there has 
been considerable difference of opinion. On the one hand, we have 
practitioners who advise the immediate emptying of the uterus, even 
when labor has commenced ; on the other, those who would leave the 
labor entirely alone. Thus Gooch said ; " Attend to the convulsions, 
and leave the labor to take care of itself; and Schroeder says: "Especi- 
allv no kind of obstetric manipulation is required for the safet}' of the 
mother," but he admits, however, that it is sometimes advisable to hasten 
the labor to ensure the safety of the child. 

In cases in which the convulsions come on during labor the pains are 
often strong and regular, the labor progresses satisfactorily, and no inter- 

^ The Puerperal Diseases, p. 1 20. 

^London Med. Rec, 1886, vol. xiv. p. 75 (extract from Busskaia Mediiz., Xo. 32, 1885^ 
p. 595). 

"" Berlin, klin. WocL, June 16, 1879. * New York Med. Bee, March 1, 1879. 



PUERPERAL INSANITY. 587 

ference is needful. In others we cannot but feel that emptying the 
uterus would be decidedly beneficial. We have to reflect, however^ 
that any active interference might, of itself, prove very irritating and 
excite fresh attacks. [Eclampsia is sometimes purely reflex, and not 
at all dangerous, although it may be alarming. The convulsive move- 
ments may arise from nerve-disturbance due to the foetal head distend- 
ing the cervix in the last stage of dilatation in primipara?. When the 
head begins to distend the perineum the convulsive seizure often ceases. 
Such patients are safer without the forceps. — Ed.] The influence of uterine 
irritation is apparent by the frequency with which the paroxysms recur 
with the pains. If, therefore, the os be undilated and labor have not 
begun, no active means to induce it should be adopted, although the 
membranes may be ruptured with advantage, since that procedure pro- 
duces no irritation. Forcible dilatation of the os, and especially turn- 
ing, are strongly contraindicated. 

The rule laid down by Tyler Smith seems that which is most advisa- 
ble to follow — that we should adopt the course which seems least likely 
to prove a source of irritation to the mother. Thus, if the fits seem 
evidently induced and kept up by the pressure of the foetus, and the 
head be within reach, the forceps may be resorted to. But if, on the 
other hand, there be reason to think that the operation necessary to 
complete delivery is likely jkv se to prove a greater source of irritation 
than leaving the case to nature, then we should not interfere. 

[If called to a case of convulsions followed by coma in a primiparse 
near term, but not in labor, draw off a little urine and examine it, as 
the patient may be far advanced in Bright's disease and the coma purely 
ursemic. In such a case little can be gained by bringing on labor and 
delivering the foetus. — Ed.] 



CHAPTER lY. 

PUERPERAL INSANITY 



Classification. — Under the head of " Puerperal ]\Iania '' writers on 
obstetrics have indiscriminately classed all cases of mental disease con- 
nected with pregnancy and parturition. The result has been untbrtu- 
nate, for the distinction between the various types of mental disorder 
has, in consequence, been very generally lost sight oW But little study 
of the subject suflices to show that the term " [>iierperal mania" is wron^- 
in more ways than one, for we lind that a large number c^t' eases are not 
cases of "mania'' at all, but of melaneholiM, whih^ a eiuisiderable niun- 
ber are not, strictly speaking, "puerperal," as they cither eoni.> on during 



588 THE PUERPERAL STATE. 

pregnancv or loDg after the immediate risks of the puerperal pericxl are 
over, being in the latter case associated with anaemia produced bv over- 
lactation. For the sake of brevity, the generic term '• puerperal insanity " 
may be employed to cover all cases of mental disorders connected with 
gestation, which may be further conveniently subdivided into three 
clashes, each ha\'ing its special characteristics, viz.: 

I. The Insanihi of Pregnancy. 

II. Puerperal Insanity, properly so called : that is, insanity coming 
on within a limited period after delivery. 

III. The Insanity of lactation. 

This division L« a strictly natural one, and includes all the cases likely 
to come under observation. The relative proportion these classes bear 
to each other can only be determined by accurate statistical observations 
on a large scale, but these materials we do not possess. The returns 
from large asylums are obviously open to objection, for only the worst 
and most confii-med cases find their way into these institutions, while by 
far the greater proportion, both before and after labor, are treated in 
their own homes. 

Proportion of these Forms of Insanity. — Taking stich returns as 
only approximate, we find from Dr. Battv Tuke ^ that in the Edinburgh 
Asylum, out of 155 cases of puerperal insanity, 28 occtirred before 
delivery, 73 during the puerperal period, and 54 during lactation. The 
relative proportions of each per hundred are as follows : 

Insanity of pregnancy. 18.06 per cent. 
Puerperal insanity. 47.09 
Insanity of lactation, 34. S3 

Marce - collects together several series of cases from various authorities, 
amounting to 310 in all, and the results are not very different from 
those of the Edinburgh Asylum, excej^t in the relatively smaller num- 
ber of cases occurring before delivery. The percentage is calculated 
from his figures : 

Insanity of preErnancy. S.06 per cent. 
Puerperal insanity. 5S.06 
Insanity of lactation, 30.30 " 

As each of these classes differs in various important respects from the 
others, it will be better to consider each separately. 

The insanity of pregnancy is. without doubt, the least common of 
the three forms. The intense mental depression which in many women 
accompanies pregnancy, and causes the patient to take a despondent 
view of her condition and to look forward to the result of her labor 
with the most gloomy apprehension, seems to be often only a lesser 
degree of the actual mental derangement which is occasionally met 
with. The relation between the two states is farther borne out by the 
fact that a large majority of cases of insanity during pregnancy are 
well-marked types of melancholia : out of 28 cases recorded by Tuke, 
15 were examples of pure melancholia, 5 of dementia with melancholia. 
In many of these the attack could be traced as developing itself out of 

^ Edin. Mtd. Joam., vol. x. ^ Traite de la FoUe des Femme? enceintes. 



PUERPERAL INSANITY. 589 

the ordinary hypochondriasis of pregnancy. In others the symptoms 
come on at a later period of pregnancy, the earlier months of which 
had not been marked by any unusual lowness of spirits. The age of 
the patient seems to have some influence, the proportion of cases between 
thirty and forty years of age being much larger than in younger 
women. A larger proportion of cases occurs in primipar^ than in 
multiparse — a fact that no doubt depends on the greater dread and 
apprehension experienced by women who are pregnant for the first time, 
especially if not very young. Hereditary disposition plays an import- 
ant part, as in all forms of puerperal insanity. It is not always easy 
to ascertain the fact of an hereditary taint, since it is often studiously 
concealed by the friends. Tuke, however, found distinct evidence of it 
in no less than 12 out of 28 cases. Furstner ^ believes that other neur- 
oses have an important influence in the causation of the disease. Out 
of 32 cases he found direct hereditary taint in 9, but in 11 more there 
was a family history of epilepsy, drunkenness, or hysteria. 

Period of Pregnancy at which it Occurs. — The period of preg- 
nancy at which mental derangement most commonly shows itself varies. 
Most generally, perhaps, it is at the end of the third or the beginning 
of the fourth month. It may, however, begin with conception, and 
even return with every impregnation. Montgomery relates an instance 
in which it recurred in three successive pregnancies. Marce distin- 
guishes between true insanity coming on during pregnancy and aggra- 
vated hypochondriasis, by the fact that the latter usually lessens after 
the third month, while the former most commonly begins after that 
date. It is unquestionable that in many cases no such distinction can 
be made, and that the two are often very intimately associated. 

The form of insanity does not differ from ordinary melancholia. 
The suicidal tendency is generally very strongly developed. Should 
the mental disorder continue after delivery, the patient may verv prob- 
ably experience a strong impulse to kill her child. ]\Iorai perversions 
have not been uncommonly observed. Tuke especially mentions' a 
tendency to dipsomania in the early months, even in Avomen who have 
not shov/n any disposition to excess at other times. He suggests that 
this may be an exaggeration of the depraved appetite or morbid crav- 
ing so commonly observed in pregnant women, just as melancholia mav 
be a further development of lowness of spirits. Laycock mentions a 
disposition to " kleptomania '^ as very characteristic of the disease. 
Casper^ relates a curious case where this occurred in a pregnant ladv of 
rank, and the influence of pregnancy in developing an irresistible tend- 
ency was pleaded in a criminal trial in which one of her pettv thefts 
had involved her. 

Prognosis. — The prognosis may be said to bo, on the m hole, t'avor- 
able. Out of Dr. Tuke's 28 cases, 19 recovered within six niomhs. 
There is little hope of a cure until after the termination ot' the proLi- 
iiancy, as out of 19 cases recorded by Marco only in 2 did tho iu>aniiv 
disappear before delivery. 

Transient Mania during- Delivery. — There is a pooiiliar lorm oi 

' Archiv fiir Psi/chtatn'e, Rand v. Ilot't _. 

* Casper's Forensic Medicine, !Ne>v SyU. Soc. vol. iv. \\ o08. 



590 THE PUERPERAL STATE. 

mental deraDgement sometimes observed during labor which is by some 
talked of as a temporary insanity. It may perhaps be more accurately 
described as a kind of acute delirium, produced in the latter stage of 
labor by the intensity of the suffering caused by the pains. According 
to ]Montgomery, it is most apt to occur as the head is passing through 
the OS uteri, or at a later period during the expulsion of the cliild. It 
may consist of merely a loss of control over the mind, during which 
the patient, unless carefully watched, might in her agony seriously 
injure herself or her child. Sometimes it produces actual hallucina- 
tion, as in the case described by Tarnier in which the patient fancied 
she saw a spectre standing at the foot of her bed which she made vio- 
lent efforts to drive away. This kind of mania, if it may be so called, 
is merely transitory in its character, and disappears as soon as the labor 
is over. From a medico-legal point of view it may be of importance, 
as it has been held by some that in certain cases of infanticide the 
mother has destroyed the child when in this state of transient frenzy 
and when she was irresponsible for her acts. In the treatment of this 
variety of delirium we must of course try to lessen the intensity of the 
suffering, and it is in such cases that chloroform will find one of its 
most valuable applications. 

True puerperal insanity has always attracted much attention from 
obstetricians, often to the exclusion of other forms of mental disturbance 
connected with the puerperal state. AVe may define it to be that form 
of insanity which comes on within a limited period after delivery, and 
which is probably intimately connected with that process. Out of 73 
examples of the disease tabulated by Dr. Tuke, only 2 came on later 
than a month after delivery, and in these there were other causes pres- 
ent ; which might possibly remove them from this class. 

Although a large number of these cases assume the character of acute 
mania, that is by no means the only kind of insanity which is observed, 
a not inconsiderable number being well-marked examples of melancho- 
lia. The distinction between them was long ago pointed out by Gooch, 
whose admirable monograph on the disease contains one of the most 
graphic and accurate accounts of puerperal insanity that has yet been 
written. 

There are also some peculiarities as to the period at which these varie- 
ties of insanity show themselves, which, taken in connection with cer- 
tain facts in their etiology, may eventually justify us in drawing a 
stron2:er line of demarcation between them than has been usual. It 
appears that cases of acute mania are aj^t to come on at a period much 
nearer delivery than melancholia. Thus, Tuke found that all the cases 
of mania came on within sixteen days after delivery, and that all cases 
of melancholia developed themselves after that j^eriod. We shall pres- 
ently see that one of the most recent theories as to the causation of the 
disease attributes it to some morbid condition of the blood. Should 
further investigation confirm this supposition, inasmuch as septic con- 
ditions of the blood are most likely to occur a short time after labor, it 
would not be an improbable hypothesis that cases of acute mania occur- 
ring within a short time after labor may depend on such septic causes, 
while melancholia is more likely to arise from general conditions favor- 



PUERPERAL INSANITY. 591 

ing the development of mental disease. This must, however, Ijc 
regarded as a mere speculation, requiring further investigation. 

Causes. — Hereditary predisposition is very frequently met with, and 
a careful inquiry into the i)atient^s history will generally show that 
other members of the faiiiily have suffered from mental derangement. 
Reid found that out of 111 cases in Bethlehem Hospital, there was 
clear evidence of hereditary taint in 45. Tuke made the same observa- 
tion in 22 out of his 73 cases ; and indeed it is pretty generally admit- 
ted by all alienist physicians that hereditary tendencies form one of the 
strongest predisposing causes of mental disturbance in the puerperal 
state. In a large proportion of cases circumstances producing deljility 
and exhaustion or mental depression have preceded the attack. Thus 
it is often found that patients attacked with it have had post-partum 
hemorrhage or have suffered from some other conditions producing 
exhaustion, such as severe and complicated labor, or they may have 
been weakened by over-frequent pregnancies or by lactation during 
the early mouths of pregnancy. Indeed, anaemia is always well marked 
in this disease. Mental conditions also are frequently traceable in con- 
nection with its production. Morbid dread during pregnancy, insuffi- 
cient to produce insanity before delivery, may develop into mental 
derangement after it. Shame and fear of exposure in unmarried 
women not unfrequently lead to it, as is evidenced by the fact that 
out of 2281 cases gathered from the reports of various asylums, above 
64 per cent, were unmarried.^ Sudden moral shocks or vivid mental 
impressions may be the determining cause in predisposed persons. 
Gooch narrates an example of this in a lady who was attacked imme- 
diately after a fright produced by a fire close to her house, the hallu- 
cinations in this case being all connected with light ; and Tyler Smith 
that of another whose illness dated from the sudden death of a relative. 
The age of the patient has some influence, and there seems to be a 
decidedly greater liability at advanced ages, especially when such women 
are pregnant for the first time. 

The possibility of the acute form of puerperal insanity coming ou 
shortly after delivery being dependent on some form of septica?mia is 
one which deserves careful consideration. The idea originated with 
Sir James Simpson, who found albumen in the urine of four patients. 
He suggested that this might probably indicate the presence in the 
blood of certain urinary constituents which might have determined 
the attack much in the same way as in eclampsia. Dr. Donkin subse- 
quently wrote an important paper," in which he Avarndy supported this 
theory, and arrived at the. conclusion " that the acute dangerous class of 
cases are examples of uraMuic blood-poisoning, of which the mania, rapid 
pulse, and other constitutional symptoms are morelv the phenomena, 
and that the aHection therefore ought to be termecl unvmic or renal 
})uerj)eral mania, in contradistinction to the other form ot' disease." He 
also suggests that the imnunliate poison may be carbonat(> (^t' aininonin, 
resulting from the decomposition of urea retained in the blood. It will 
be observed, therefore, tltat the pathological condition producing puer- 
peral mania wn)uld, supposing this theory to be correct, be priH'isely the 
^ JoHrn. of Mental Scivnce, 1870 71. p. \o9. ' Kdin. Mt\l Joiirn., vol. vii. 



592 THE PUERPERAL STATE. 

same as that which at other times is supposed to give rise to puerperal 
eclampsia. There can be no doubt that the patieut immediately after 
delivery is in a condition rendering her peculiarly liable to various forms 
of septic disease ; and it must be admitted that there is no inherent 
improbability in the supposition that some morbid material circulating 
in the blood may be the effective cause of the attack in a person other- 
wise predisposed to it. It is also certain, as I have already pointed out, 
that there are two distinct classes of cases, differing according to the 
period after delivery at which the attack comes on. \Yhether this 
difference depends on the presence in the blood of some septic matter 
— especially urinary excreta — is a question which our knowledge by 
no means justifies us in answering; it is, however, one which well 
merits further careful study. 

It is only fair to point out some difficulties which appear to militate 
against the view which Dr. Donkin maintains. In the first place, the 
albuminuria is merely transient, while its supposed effects last for weeks 
or months. Sir James Simpson says, with regard to his cases : " I have 
seen all cases of albuminuria in puerperal insanity disappear from the 
urine within fifty hours of the access of the malady. The general 
rapidity of its disappearance is perhaps the principal, or indeed the 
only, reason why this complication has escaped the notice of those 
physicians among us who devote themselves with such ardor and zeal 
to the treatment of insanity in our public asylums." This apparent 
anomaly Simpson attempts to explain by the hypothesis that when 
once the uraemic poisoning has done its work and set the disease in 
progress the mania progresses of itself. This, however, is pure specu- 
lation, and in the supposed analogous case of eclampsia the albuminuria 
certainly lasts as long as its effects. It is not easy to understand also 
w^hy ursemic poisoning should in one case give rise to insanity, and in 
another to convulsions. For all we know to the contrary, transient 
albuminuria may be much more common after delivery than has been 
generally supposed, and further investigation on this point is required. 
Albumen is by no means unfrequently observed in the urine for a short 
time in various conditions of the body, without any serious consequences, 
as, for example, after bathing ; and we may too readily draw an unjusti- 
fiable conclusion from its detection in a few cases of mania. There are, 
however, many other kinds of blood-poisoning besides uraemia which 
may have an influence in the production of the disease, and it is to be 
hoped that future observations may enable us to speak with more cer- 
tainty on this point. 

The prognosis of puerperal insanity is a point which will always 
deeply interest those who have to deal with so distressing a malady. It 
niay resolve itself into a consideration of the immediate risk to life and 
of the chances of ultimate restoration of the mental faculties. It is an 
old aphorism of Gooch's — and one the correctness of Avhich is justi- 
fied by modern experience — that ^^ mania is more dangerous to life, 
melancholia to reason.'^ It has very generally ])een supposed that the 
immediate risk to life in puerperal mania is not great, and on the whole 
this may be taken as correct. Tuke found that death took place from 
all causes in 10.9 per cent, of the cases under observation; these, how- 



PUERPERAL INSANITY. 593 

ever, were all women who had been admitted into asylums, and in whom 
the attack may be assumed to have been exceptionally severe. Great 
stress was laid by Hunter and Gooch on extreme rai)idity of the pulse 
as indicating a fatal tendency. There can be no doubt that it is a symp- 
tom of great gravity, but by no means one which need lead us to despair 
of our patient's recovery. The most dangerous class of cases are those 
attended with some inflammatory complication ; and if there be marked 
elevation of temperature, indicating the presence of some such concom- 
itant state, our prognosis must be more grave than when there is mere 
excitement of the circulation. 

Post-mortem Sig-ns.— There are no marked post-mortem signs 
found in fatal cases to guide us in forming an opinion as to the nature 
of the disease. '^No constant morbid changes,'' says Tyler Smith, 
"are found within the head, and most frequently the only condition 
found in i\\Q brain is that of unusual paleness and exsanguinity. 
Many pathologists have also remarked upon the extremely'' empty 
condition of the blood-vessels, particularly the veins." 

The duration of the disease varies considerably. Generally speak- 
ing, cases of mania do not last so long as melancholia, and recovery 
takes place within a period of three months, often earlier. Very few 
of the cases admitted into the Edinburgh Asylum remained there more 
than SIX months, and after that time the chances of ultimate recoverv 
greatly lessened. When the patient gets well it often happens that her 
recollection of the events occurring during her illness is lost; at other 
times the delusions from which she suffered remain, as, for example, in 
a case which was under my care in which the personal antipathies which 
the patient formed when insane became permanently established. 

Insanity of Lactation.— 54 out of the 155 cases collected bv Dr 
Tuke were examples of the insanity of lactation, which would appear* 
therefore, to be nearly twice as common as that of pregnancv but con- 
siderably less so than the true puerperal form. Its dependence on 
causes producing anaemia and exhaustion is obvious and well marked 
In the large majority of cases it occurs in multiparre who have been 
debilitated by frequent pregnancies and bv length of nursing. AMien 
occurring in primipara^, it is generally in women who have sut!ered 
from post-partum hemorrhage or other causes of exhaustion, or who^e 
constitution was such as should have contraindicated anv attempt at 
lactation. The bruit de diable is almost invariablv present in the veins 
of the neck, indicating the impoverished condition of the blood. 

The type is flir more frequently melancholic than maniacal, and when 
the latter form occurs the attack is much more transient than in true 
puerperal insanity. The danger to life is not oreat, especially it' the 
cause producing debility be recognized and at once removed.' 

There seems, however, to be more risk of the insanitv becomino- por- 
manentthan m the other forms. In 12 out of Dr. tuke's ca^e< the 
melancholia degenerated into dementia and the patients became hope- 
lessly insane. , ^ 

Symptoms.— The symptoms of these various forms o\: insanitv artr 
practically the same as in the non-pregnant state. 

Generally in cases of mania there is nlore or Uvs pivmonitoiv iiuliea- 



694 THE PUERPERAL STATE. 

tion of mental disturbance, which may pass unperceived. The attack 
is often preceded by restlessness and loss of sleep, the latter being a yery 
common and well-marked symptom, or if the patient do sleep her rest 
is broken and disturbed by dreams. Causeless dislikes to those around 
her are often obseryed ; the nurse, the husband, the doctor, or the child 
becomes the object of suspicion, and unless proper care be taken the child 
may be seriously injured. As the disease adyances the patient becomes 
incoherent and rambling in her talk, and in a fully-deyeloped case she 
is incessantly pouring forth an unconnected jumble of sentences out of 
which no meaning can be made. Often some preyalent idea which is 
dwelling in the patient's mind can be traced running through her rav- 
ings, and it has been noticed that this is frequently of a sexual charac- 
ter, causing women of unblemished reputation to use obscene and dis- 
gusting language which it is difficult to understand eyen when heard. 
The tendency of such patients to make accusations impugning their 
own chastity was specially insisted on by many eminent authorities in 
a recent celebrated trial, when Sir James Simpson stated that in his 
experience " the organ diseased gaye a type to the insanity, so that 
with women suffering from affections of the genital organs the delu- 
sions would be more likely to be connected with sexual matters." 
Religious delusions — as a fear of eternal damnation or of having 
committed some unpardonable sin — are of frequent occurrence, but 
perhaps more often in cases which are tending to the melancholic type. 
There is generally intolerable restlessness, and the patient's Ayhole man- 
ner and appearance are those of excessive excitement. She may refuse 
to remain in bed, may tear off her clothes, or attempt to injure herself. 
The suicidal tendency is often very marked. In one case under my 
care the patient made incessant efforts to destroy herself, which were 
only, frustrated by the most careful watching ; she endeavored to 
strangle herself with the bed-clothes, to swallow any article she could 
lay hold of, and even to gouge out her own eyes. Food is generally 
persistently refused, and the utmost coaxing may fail in inducing the 
patient to take nourishment. The pulse is rapid and small, and the 
more violent the excitement and furious the delirium the more excited 
is the circulation. The tongue is coated and furred, the bowels consti- 
pated and disordered, and the feces as w^ell as the urine are frequently 
passed involuntarily. The urine is scanty and high-colored, and after 
the disease has lasted for some time becomes loaded with phosphates. 
The lochia and the secretion of milk generally become arrested at the 
commencement of the disease. The Ayaste of tissue, from the incessant 
restlessness and movement of the patient, is very great, and if the dis- 
ease continue for some time she falls into a condition of marasmus, 
w^hich may be so excessive that she becomes wasted to a shadow of her 
former size. 

When the insanity assumes the form of melancholia its advent is 
more gradual. It may commence with depression of spirits without 
any adequate cause, associated with insomnia, disturbed digestion, head- 
ache, and other indications of bodily derangement. Such symptoms, 
showing themselves in women who have been nursing for a length of 
time or in whom any other evident cause of exhaustion exists, should 



PUERPERAL INSANITY. 595 

never pass unnoticed. Soon the signs of mental depression increase 
and positive delusions show themselves. These may vary much in 
their amount, but they are all more or less of the same type, and very 
often of a religious character. The amount of constitutional disturb- 
ance varies much. In some cases which approach in character those of 
mania there is considerable excitement, rapid pulse, furred tongue, and 
restlessness. Probably cases of acute melancholia, coming on during 
the puerperal state, most often assume this form. In others, again, 
there is less of these general symptoms, the patients are profoundly 
dejected, and sit for hours without speaking or moving, but there is not 
much excitement ; and this is the form most generally characterizing 
the insanity of lactation. In all cases there is a marked disinclination 
to food. There is also, almost invariably, a disposition to suicide ; and 
it should never be forgotten in melancholic cases that this may develop 
itself in an instant, and that a moment's carelessness on the part of the 
attendants may lead to disastrous results. 

Treatment. — Bearing in mind what has been said of the essential 
character of puerperal insanity, it is obvious that the course of treat- 
ment must be mainly directed to maintain the strength of the patient, 
so as to enable her to pass through the disease without fatal exhaustion 
of the vital powers, while we endeavor at the same time to calm the 
excitement and give rest to the disturbed brain. Any over-active 
measures — for example, bleeding, blistering the shaven scalp, and the 
like — are distinctly contraindicated. 

There is a general agreement on the part of alienist physicians that 
in cases of acute mania the two things most needed are a sufficient 
quantity of suitable food and sleep. 

Every endeavor should be made to induce the patient to take plenty 
of nourishment to remedy the defects of the excessive waste of tissue 
and support her strength until the disease abates. Dr. Blandford, who 
has especially insisted on the importance of this, says:^ ''Xow, with 
regard to the food, skilful attendants will coax a patient into taking a 
large quantity, and we can hardly give too much. Messes of minced 
meat with potato and greens, diluted with beef-tea, bread and milk, rum 
and milk, arrowroot, and so on, may be got down. Xever give mere 
liquids as long as you can get down solids. As the malady }n'ooressos 
the tongue and mouth may become so dry and foul that nothing but 
liquids can be swallowed ; but, reserving our beef-tea and brandy, lot 
us give plenty of solid food while we can." 

The patient may in mania, as well as in melancholia, perhaps oven 
more in the latter, obstinately refuse to take nourishment at all, and wo 
may be compelled to use force. Various contrivances have boon 
employed for this purpose. One of the simplest is introducing a dos- 
sort-spoon Ibrcibly between the tooth, the patient being controlkxi by an 
adequate number of attendants, and slowly injecting into the mouth 
suitable nourishment by an india-rubber bottle with an ivory nozzle, 
such as is sold by all chemists. Care nuist bo taken not to injoot nuuv 
than an ounce at a time, and to allow the patient io bivatho botwtvn 
each deglutition. So extreme a measure will seldom bo roquirod it' the 

^ Blandford, huanitxi and its Treatment. 



596 THE PUERPERAL STATE. 

patient have experienced attendants, who can overcome her resistance 
to food by gentler means ; but it may be essential, and it is far better 
to employ it than to allow the patient to become exhausted from want 
of nourishment. In one case I had to feed a patient in this way three 
times a day for several weeks, and used for the purpose a contrivance 
known in asylums as Paley's feeding-bottle, which reduced the difficulty 
of the process to a minimum. Beef-tea or strong soup mixed with 
some farinaceous material, such as Revalenta Arabica or wheaten flour, 
or milk, forms the best mess for this purpose. 

In the early stages the patient is probably better without stimulants, 
which seem only to increase the excitement. As the disease progresses 
and exhaustion becomes marked, it may be necessary to have- recourse 
to them. In melancholia they seem to be more useful, and may be 
administered wdth greater freedom. 

The state of the bowels requires special attention. They are almost 
always disordered, the evacuations being dark and offensive in odor. In 
the early stages of the disease the prompt clearing of the bowels by a 
suitable purgative sometimes has the effect of cutting short an impend- 
ing attack. A curious example of this is recorded by Gooch, in which 
the patient's recovery seemed to date from the free evacuation of the 
bowels. A few grains of calomel or a dose of compound jalap powder 
or of castor oil may generally be readily given. During the continu- 
ance of the illness the state of the primse vise should be attended to, 
and occasional aperients will be useful, but strong and repeated purga- 
tion is hurtful from the debility it produces. 

One of the most important points of treatment is to procure sleep. 
For this purpose there is no drug so valuable as the hydrate of chloral, 
either alone or in combination with bromide of sodium, which has a dis- 
tinct effect in increasing its hypnotic action. Given in a full dose at 
bedtime, say 15 grs. to gss, it rarely fails in procuring at least some 
sleep, and in the early stage of acute mania this may be followed by 
the best effects. It may be necessary to repeat this draught night after 
night during the acute stage of the malady. If we cannot induce the 
patient to swallow the medicine, it may be given in the form of enema. 

It is generally admitted that in mania preparations of opium, 
formerly much relied on in the treatment of the disease, are apt to do 
more harm than good. Dr. Blandford gives a strong opinion on this 
point. He says : " In prolonged delirious mania I believe opium 
never does good, and may do great harm. We shall see the effects of 
narcotic poisoning if it be pushed, but none that are beneficial. This 
applies equally to opium given by the mouth and by subcutaneous 
injection. The latter, as it is more certain and effectual in producing 
good results, is also more deadly when it acts as a narcotic poison. 
After the administration of a dose of morphia by the subcutaneous 
method the patient will probably at once fall asleep, and we congratu- 
late ourselves that our long-wished-for object is attained. But after half 
an hour or so the sleep suddenly terminates, and the mania and excite- 
ment are worse than before. Here you may possibly think that had 
the dose been larger instead of half an hour's sleep you would have 
obtained one of longer duration, and you may administer more, but 



PUERPERAL INSANITY. o97 

with a like result. Large doses of morphia not merely fail to produce 
refreshing sleep ; they poison the patient, and 2:)roduce, if not the symp- 
toms of actual narcotic poisoning, at any rate that typhoid condition 
which indicates prostration and approaching collapse. 1 believe there 
is no drug the use of which more often becomes abused than that of 
opium/' It is otherwise in cases of melancholia, especially in the more 
chronic forms. In these opiates in moderate doses, not pushed to excess, 
may be given with great advantage. The subcutaneous injection of 
morphia is by far the best means of exhibiting the drug, from its rapid- 
ity of action and facility of administration. 

There are other methods of calming the excitement of the patient 
besides the use of medicines. The prolonged use of the warm bath, 
the patient being immersed in water at a temperature of 90° or 92° 
for at least half an hour, is highly recommended by some as a sedative. 
The wet pack serves the same purpose, and is more readily applied in 
refractory subjects. 

Judicious nursing is of primary importance. The patient should 
be kept in a cool, well- ventilated, and somewhat darkened room. If 
j^ossible she should remain in bed, or at least endeavors should be made 
to restrain the excessive restless motion, which has so much effect in 
promoting exhaustion. The presence of relatives and friends, especially 
the husband, has generally a prejudicial and exciting effect ; and it is 
advisable to place the patient under the care of nurses experienced in 
the management of the insane, who as strangers are likely to have more 
control over her. It is not too much to say that much of the success 
in treatment must depend on the manner in which this indication is 
met. Rough, unskilled nurses, who do not know how to use gentleness 
combined with firmness, will certainly aggravate and prolong the dis- 
order. Inasmuch as no patient should be left unwatched by day or 
night, more than one nurse is essential. 

The question of the removal of the patient to an asylum is one which 
will give rise to anxious consideration. As the foct of having been 
under such restraint of necessity fixes a certain lasting stigma upon a 
])atient, this is a step which every one would wish to avoid if possible. 
In cases of acute mania, which will probably last a comparatively short 
time, home treatment can generally be efticiently carried out. ^luch 
must depend on the circumstances of the patient, l^ those be of a 
nature which preclude the possibility of her obtaining thoroughly eth- 
cient nursing and treatment in her own home, it is advisable to remove 
lier to a place where these essentials can be obtained, even at the cost of 
some subsequent annoyance. In cases of chronic melancholia, the man- 
agement of which is on the whole more dillicult, the necessity for such 
a measure is more likely to arise, and should not be postjxMied too late. 
INIany examples of incurable dementia arising out of puerperal melan- 
cliolia can be traced to unnecessary delay in ])lacing the patients under 
(he most favorable conditions for recovery. 

Treatment during- Convalescence. — When convalesconco is com- 
mencing change of air and scene will often be found ot' uivat value. 
Kemoval to some (piiet country place, where the [)atient can enjov abun- 
dance of air and exercise in the company of her nurso. without the 



598 THE PUERPERAL STATE. 

excitement of seeing many people, is especially to be recommended. 
Great cantion must be used in admitting the visits of relatives and 
friends. In two cases under my own care the patients relapsed when 
apparently progressing favorably because the husbands insisted, contrary 
to advice, on seeing them. On the other hand, Gooch has pointed out 
that when the patient is not recovering, when month after month has 
been passed in seclusion without any improvement, the visit of a friend 
or relative may produce a favorable moral impression and inaugurate a 
change for the better. It is probably in cases of melancholia, rather 
than in mania, that this is likely to happen. The experiment may 
under such circumstances be worth trying, but it is one the result of 
which we must contemplate with some anxiety. 



CHAPTER y. 

PUEKPERAL SEPTICEMIA. 

Difference of Opinion as to Puerperal Fever. — There is no 
subject in the whole range of obstetrics which has caused so much 
discussion and difference of opinion as that to which this chapter 
is devoted. Under the name of ^^ puerperal fever" the disease we 
have to consider has given rise to endless controversy. One writer 
after another has stated his view of the nature of the affection with 
dogmatic precision, often on no other grounds than his own preconceived 
notions and an erroneous interpretation of some of the post-mortem 
appearances. Thus, one states that puerperal fever is only a local 
inflammation, such as peritonitis ; others declare it to be phlebitis, metri- 
tis, metro-peritonitis, or an essential zymotic disease, sui generis^ which 
affects lying-in women only. The result has been a hopeless confusion, 
and the student rises from the study of the subject with little more use- 
ful knowledge than when he began. Fortunately, modern research is 
beginning to throw a little light upon this chaos. 

Modern View of the Disease. — The whole tendency of recent 
investigation is daily rendering it more and more certain that obstetri- 
cians have been led into error by the special virulence and intensity of 
the disease, and that they have erroneously considered it to be some- 
thing special to the puerperal state, instead of recognizing in it a form 
of septic disease practically identical with that which is familiar to sur- 
geons under the name of pyaemia or septicaemia. 

If this view be correct, the term " puerperal fever," conveying the 
idea of a fever such as typhus or typhoid, must be acknowledged to be 
misleading, and one that should be discarded as only tending to confu- 
sion. Before discussing at length the reasons which render it probable 



PUERPERAL SEPTICJEMIA. 599 

that the disease is in no way specific or peculiar to the puerperal state, 
it will be well to relate briefly some of the leading facts connected with it. 

History. — More or less distinct references to the existence of the 
so-called puerperal fever are met with in the classical authors, proving 
beyond doubt that the disease was well known to them ; and Hippoc- 
rates, besides relating several cases the nature of which is unquestion- 
able, clearly recognizes the possibility of its originating in the retention 
and decomposition of portions of the placenta. Although Harvey and 
other writers showed that they were more or less familiar with it, and 
even made most creditable observations on its etiology, it was not until 
the latter half of the last century that it came prominently into notice. 
At that time the frightful mortality occurring in some of the principal 
lying-in hospitals, especially in the Hotel Dieu at Paris, attracted atten- 
tion, and ever since the disease has been familiar to obstetricians. 

Mortality in Lying-in Hospitals. — Its prevalence in hospitals in 
which lying-in women are congregated has been constantly observed both 
in England and elsewhere, occasionally producing an apj^alling death- 
rate, the disease, when once it has appeared, frequently spreading from 
one patient to another in spite of all that could be done to arrest it. It 
would be easy to give many startling instances of this. Thus it pre- 
vailed in London in the years 1760, 1768, and 1770 to such an extent 
that in some lying-in institutions nearly all the patients died. Of the 
Edinburgh Infirmary in 1773 it is stated that " almost every woman as 
soon as she was delivered, or perhaps about twenty-four hours after, was 
seized with it, and all of them died, though every method was used to 
cure the disorder.^^ On the Continent, where the lying-in institutions 
are on a much larger scale, the mortality was equally great. Thus in 
the Maison d'Accouchements of Paris in a number of different years 
sometimes as many as 1 in 3 of the women delivered died, on one 
occasion 10 women dying out of 15 delivered. Similar results were 
observed in other great continental hospitals, as in Vienna, Avhere, in 
1823, 19 per cent, of the cases died, and in 1842, 16 per cent.; and in 
Berlin in 1862 hardly a single patient escaped, the hospital being 
eventually closed. 

Such facts, the correctness of which is beyond any question, prove to 
demonstration the great risk which may accompany the aggregation of 
lying-in women. Whether they justify the conclusion that all lying- 
in hospitals should be abolished is another and a very wide question 
which can scarcely be satisfactorily discussed in a practical work. It is 
to be observed, however, that most of the cases in which the disease 
produced sucli disastrous results occurred before our more recent know- 
ledge of its mode of propagation was acquired, when no sufficient hygienic 
precautions were adopted, when ventilation was little thought (^f, and 
when, in a word, every condition prevailed that would tend io tavor the 
S})read of a contagious disease from one patient to another. More roeenr 
(\\})erience proves tliat when the contrary is tlie case the occurrence o( 
epidemics of this kind may be entirely prevented ami the mortality 
approximated to that of h6me practice. llie results almost universally 
obtained of late years by the intnxhu^tion of strict antisepsis int(^ lying- 
in institutions aflbrd a most instructive connnentarv on the causes of 



600 THE PUERPERAL STATE. 

puerperal fever. Thus, iu the Maternite in Paris the mortality from 
1858 to 1870 was 1 iu 11 ; at the present time it is only 1 in 100. At 
the Foundling Hospital in St. Petersburg the mortality before the intro- 
duction of antiseptics was 1 in 27 ; since their use, 1 in 147. Similar 
satisfactory results have been reported in lying-in institutions in London, 
America, and indeed universally whatever antiseptic precautions have 
been adopted.^ 

The more closely the history of these outbreaks in hospitals is studied, 
the more apparent does it become that they are not dependent on miasm 
necessarily produced by the aggregation of puerperal patients, but on 
the direct conveyance of septic matter from one patient to another. 

In numerous instances the disease has been said to be generally 
epidemic in domiciliary practice, much in the same way as scarlet 
fever or any zymotic complaint might be. Such epidemics are described 
as having occiu'red in London in 1827-28, in Leeds in 1809-12, in 
Edinburgh in 1825, and many others might be cited. There is, how- 
ever, no sufficient groimd for believing that the disease has ever been 
epidemic in the strict sense of the word. That numerous cases have 
often occurred in the same place and at the same time is beyond ques- 
tion, but this can easily be explained without admitting an epidemic 
influence, knowing, as we do, how readily septic matter may be con- 
veyed from one patient to another. In many of the so-called epidemics 
the disease has been limited to the patients of certain midwives or prac- 
titioners, while those of others have entirely escaped — a fact easily under- 
stood on the assumption of the disease being produced by septic matter 
coitveyed to the patient, but irreconcilable with the view of general 
epidemic influence. AVe are not in possession of any reliable statistics 
of the mortality arising from puerperal septicaemia in ordinary general 
practice. It has, however, been well pointed out in the report on puer- 
peral fever presented by the Obstetrical Society of Berlin to the Prussian 
minister of health ^ that not only do the published returns of death from 
metria afford no reliable estimate of the actual mortality from this som'ce, 
but that they are very far more numerous than deaths from any other 
cause in connection with pregnancy and childbirth. 

Theories Advanced Regarding" its Nature. — It would be a useless 
task to detail at length the theories that have been advanced to explain 
the disease. Indeed, it may safely be held that the supposed necessit}^ 
of providing a theory which would explain all the facts of the disease 
lias done more to surround it with obscurity than even the difficitlties 
of the subject itself. If any real advance is to be made, it can only be 
by adopting a humble attitude, by admitting that we are only on the 
threshold of the inquiry, and by a careful observation of clinical facts 
without drawing from them too positive deductions. 

Theory of its Local Origin. — ]Many have taught that the disease 
is essentially a local inflammation, producing secondary constitutional 
effects. This view doubtless originated from too exclusive attention 

^ See '"The Prevention of Lying-in Fever,"' by Wassily Sutugin, Edin. Med. Journ., 
vol. 1SS4-S5, p. 781. 

^ " Dentsclirift der Puerperaljfieber-Commission," Zeitschrift j. Geb. u. Gyn., 1878, 
Band iii. S. 1, translated in Edin. Med. Journ., vol. 1878-79, p. 435. 



PUERPERAL SEPTICEMIA. 601 

to the morbid changes found on post-mortem examination. Extensive 
peritonitis, phlebitis, inflammation of the lymphatics or of the tissues 
of the uterus are very commonly found after death ; and each of these 
has in its turn been believed to be the real source of the disease. This 
view finds but little favor with modern pathologists, and is in so 
many ways inconsistent with clinical facts that it may be considered to 
be obsolete. No one of the conditions above mentioned is universally 
found, and in the worst cases definite signs of local inflammation may 
be entirely absent. Nor will this theory explain the conveyance of the 
disease from one patient to another or the peculiar severity of the con- 
stitutional symptoms. 

Theory of an Essential Zymotic Fever. — A more admissible 
theory, and one which has been extensively entertained, is that there 
is an essential zymotic fever peculiar to, and only attacking, puerperal 
women, which is as specific in its nature as typhus or typhoid, and to 
which the local phenomena observed after death bear the same relation 
that the pustules on the skin do to smallpox or the ulcers in the intes- 
tinal glands to typhoid. This fever is supposed to spread by contagion 
and infection, and to prevail epidemically both in private and in hos- 
pital practice. The most recent exponent of this view is Fordyce 
Barker, who in his excellent work on the Puerperal Diseases has 
entered at length into all the theories of the disease. He, like others 
who hold his opinions, has, I cannot but think, entirely failed to bring 
forward any conclusive evidence of the existence of such a specific fever. 
It is no doubt true that in typhus and typhoid and other undoubted 
examples of this class of disease there are well-marked local secondary 
phenomena, but then they are distinct and constant. He makes no 
attempt to prove that anything of the kind occurs in puerperal fever. 
On the contrary, probably there are no two cases in which similar local 
phenomena occur, nor is there any case in which the most practised 
obstetrician could foretell either the course and the duration of the ill- 
ness or the local phenomena. Again, this theory altogether fails to 
explain the very important class of cases which can be distinctly traced 
to sources originating in the patient herself — viz. the absorption of septic 
matter from decomposing coagula and the like. Barker meets this dif- 
ficulty by placing such cases of auto-infection under a separate category, 
admitting that they are examples of septicaemia. But he fails to show 
that there is any diiference in symptomatology or })ost-morteni signs 
between them and the cases he believes to depend on an essential fever; 
nor would it be possible to distinguish the one from the other by either 
their clinical or ])ath()logical history. 

Theory of its Identity with Surgical Septiceemia. — The niodorn 
view, which holds that the disease is, in fact, identical with the ci)ndi- 
tion known as ])yiX!mia or septicaMuia, is by no means free iVom objec- 
tions, and much [>atient clinical investigation is recpiired to give a s;uis- 
factory exphination of certain peculiarities which the disease presents; 
but in s])ite of these ditlicnlties, which time may serve to renu>ve, it 
oflers a far better ex})laiultion of the phenomena observcil than aiiv 
other that has yet been advanced. 

According to this theory, the so-called puerperal t'over is produced by 



602 THE PUERPERAL STATE. 

the absorption of septic matter into the system through solutions of 
continuity in the generative tract, such as always exist after labor. It 
is not essential that the poison should be peculiar or specific; for, just 
as in surgical pysemia, any decomposing organic matter, either originat- 
ing within the generative organs of the patient herself or coming from 
without, may set up the morbid action. 

In describing the disease under discussion I shall assume that, so far 
as our present knowledge goes, this view is the one most consonant with 
facts ; but, bearing in mind that very little is yet known of surgical 
sejDticeemia, it must not be expected that obstetricians can satisfactorily 
explain all the phenomena they observe. 

The best basis of description I know of is that given by Burdon 
Sanderson, when he says : " In every pysemic process you may trace a 
focus, a centre of origin, lines of diffusion or distribution, and secondary 
results from the distribution — in every case an initial process from which 
infection commences, from which the infection spreads, and secondary 
processes which come out of this primary one.'' ^ Adopting this divis- 
ion, I shall first treat of the mode in which the infection may com- 
mence in obstetric cases, and point out the special difficulties which 
this part of the subject presents. 

Channels through "which Septic Matter may be Absorbed. — 
The fact that all recently-delivered women present lesions of continuity 
in the generative tract, through which septic matter, brought into con- 
tact with them, may be readily absorbed, has long been recognized. 
The analogy between the interior of the uterus after delivery and the 
surface of a stump after amputation was particularly insisted on by 
Cruveilhier, Simpson, and others — an analogy which was, to a great 
extent, based on erroneous conceptions of what took place, since they 
conceived that the whole interior of the uterus was bared. It is now 
well known that this is not the case ; but the fact remains that at the 
placental site, at any rate, there are open vessels through which absorp- 
tion may readily take place. That absorption of septic material occurs 
through this channel is probable in certain cases in which decomposing 
materials exist in the interior of the uterus, especially when from 
defective uterine contraction the venous sinuses are abnormally patu- 
lous and are not occluded by thrombi. It is difficult to understand 
how septic matter, introduced from Avithout, can reach the placental 
site. Other sites of absorption are, however, always available. These 
exist in every case in the form of slight abrasions or lacerations about 
the cervix or in the vagina, or, especially in primiparse, about the four- 
chette and perineum. There is even some reason to think that absorp- 
tion of septic matter may take place through the mucotts membrane of 
the vagina or cervix without any breach of surface. This might serve 
to account for the occasional, although rare, cases in which symptoms 
of the disease develop themselves before delivery, or so soon after it as 
to show that the infection must have preceded labor ; nor is there any 
inherent improbability in the supposition that septic material may be 
occasionally absorbed through the unbroken mucous membrane, as is 
certainly the case with some poisons — for example, that of syphilis. 

^ Clinical Transactions, vol. vii. p. cviii. 



PUERPERAL SEPTICEMIA. 603 

Hence there is no difficulty in recognizing tlie similarity of a lying-in 
woman to a patient suffering from a recent surgical lesion, or in under- 
standing how septic matter conveyed to her during or shortly after labor 
may be absorbed. It is necessary, however, to suppose that absorption 
takes place immediately or very shortly after these lesions of continuity 
are formed, for it is well known that the power of absorption is arrested 
after they have commenced to heal. This fact may explain the cases 
in which sloughing about the perineum or vagina exists without any 
septicaemia resulting, or the far from uncommon cases in which an 
intensely fetid lochial discharge may be present a few days after 
delivery without any infection taking place. 

The character and sources of the septic matter constitute one of the 
most obscure questions in connection with septicaemia, and that which 
is most open to discussion. 

Division into Autog-enetic and Heterogenetic Cases. — The most 
practical division of the subject is into cases in which the septic matter 
originates within the patient, so that she infects herself, the disease then 
being properly autogenetic ; and into those in which the septic matter 
is conveyed from without and brought into contact with absorptive 
surfaces in the generative tract, the disease then being lieterogenetic. 

Sources of Self-infection. — The sources of auto-infection may be 
various, but they are not difficult to understand. Any condition giving 
rise to decomposition, either of the tissues of the mother herself, of 
matters retained in the uterus or vagina that ought to have been expelled, 
or decomposing matter derived from a putrid foetus, may start the sep- 
ticsemic process. Thus it may happen that from continuous pressure on 
the maternal soft parts during labor sloughing has set in, or there may 
be already decomposing material present from some previous morbid 
state of the genital tracts, as in carcinoma. A more common origin is 
the retention of coagula or of small portions of membrane or of pla- 
centa in the interior of the uterus, which have putrefied from access of 
air; or in the decomposition of the lochia. That the retention of por- 
tions of the placental tissue has at all times been the cause of septicae- 
mia may be illustrated by the case of the Duchesse d'Orleans (in the 
time of Louis XIII. ), who had an easy labor, but died of childbed 
fever. An examination was made by the leading physicians of Paris, 
in their report of which it was stated: "On the right side of the womb 
was found a small portion of after-birth, so firndy adherent that it 
could hardly be torn off by the finger-nails."^ The reason why self- 
infection does not more often occur from such sources, since more or 
less decomposition is of necessity so often present, has already been 
referred to in tlie fact that absorj)tion of such matters is not apt to iHvur 
when the lesions of continuity, always existing after parturition, have 
commenced to heal. This observation may also serve to explain how 
previous bad states of health, by interfering with the healthy reparative 
process occurring after delivery, may predispose to self-infection. It is 
interesting to note that puer})eral septicjvmia arising fn>m such sourcvs 
is not limited to the human race. In tiie debate on pyiiMuia at the 
Clinical Society, Mr. Hutchinson recorded several well-marked exani- 

' Louise Bourqcois, bv (nnnli 11. 



604 THE PUERPERAL STATE. 

pies occuring in ewes iu whose uteri portions of retained placenta were 
found. 

Source of Heterogenetic Infection. — The sources of septic matter 
conveyed from without are much more difficult to trace, and there are 
many facts connected with heterogenetic infection which are very diffi- 
cult to reconcile with theory, and of which, it must be admitted, we 
are not yet able to give a satisfactory explanation. 

It is probable that any decomposing organic matter may infect, but 
that some forms operate with more certainty and greater virulence than 
others. 

One of these, which has attracted special attention, is what may be 
termed cadaveric poison, derived from dissection of the dead subject in 
the anatomical and post-mortem theatres, and conveyed to the genital 
tract by the hands of the accoucheur. Attention was particularly 
directed to this source of infection by the observations of Semmelweiss, 
who showed that in the division of the Vienna Lying-in Hospital 
attended by medical men and students who frequented the dissecting- 
rooms the mortality was seldom less than 1 to 10, while in the division 
solely attended by women the mortality never exceeded 1 to 34 ; the 
number of deaths in the former division at once falling to that of the 
latter so soon as proper precautions and means of disinfection were used. 
Many other facts of a like nature have since been recorded which ren- 
der this origin of puerperal septicaemia a matter of certainty. An 
interesting example is related by Simpson with characteristic candor : 
^^In 1836 or 1837, Mr. Sidey of this city had a rapid succession of five 
or six cases of puerperal fever in his practice at a time when the dis- 
ease was not known to exist in the practice of any other practitioners in 
the locality. Dr. Simpson, who had then no firm or proper belief in 
the contagious propagation of puerperal fever, attended the dissection of 
Mr. Sidey's patients and freely handled the diseased parts. The next 
four cases of midwifery which Dr. Simpson attended were all affected 
with puerperal fever, and it was the first time he had seen it in prac- 
tice. Dr. Patterson of Leith examined the ovaries, etc. The three 
next cases which Dr. Patterson attended in that town were attacked 
with the disease."^ Negative examples are of course brought forward 
of those who have attended post-mortem examinations without injury 
to their obstetric patients, which merely prove that the cadaveric poison 
does not, of necessity, attach itself to the hands of the dissector; and 
no amount of such testimony can invalidate such positive evidence as 
that just narrated. Barnes believes that there is not so much danger 
attending the dissection of patients who have died of any ordinary dis- 
ease, but that the risk attending the dissection of those who have died 
of infectious or contagious complaints is verj^ great indeed.^ I pre- 
sume there is no doubt that tlie risk is greater when the subject has died 
from zymotic disease ; but the distinction is too delicate to rely on, and 
the attendant on midwifery will certainly err on the safe side by avoid- 
ing as much as possible having anything to do with the conduct of dis- 
sections or post-mortem examinations. 

^Selected Obstei. Works, p. 508. 

2 "Lectures on Puerperal Fever," Lancet, 1865, vol. ii. p. 112. 



PUERPERAL SEPTICAEMIA. 605 

Infection from Erysipelas. — Another possible source of infection is 
erysipelatous disease in all its forms. The intimate connection between 
erysipelas and surgical pyaemia has long been recognized by surgeons, 
and the influence of erysipelas in producing puerperal septicaemia has 
been specially observed in surgical hospitals into which lying-in patients 
were also admitted. Trousseau relates instances of this kind occurring 
in Paris. The only instance that I know of in London was in the 
lying-in ward of King's College Hospital, where, in spite of every 
hygienic precaution, the mortality was so great as to necessitate the 
closure of the ward. Here the association of erysipelas Avith puerperal 
septicaemia was again and again observed, the latter proving fatal in 
direct proportion to the prevalence of the former in the surgical wards. 
The dependence of the two on the same poison was in one instance 
curiously shown by the fact of the child of a patient who died of puer- 
peral septicaemia dying from erysipelas which started from a slight abra- 
sion produced by the forceps. A more recent and very remarkable 
example is related by Dr. Lombe Atthill.^ A patient suffering from 
erysipelas was admitted into the Eotunda Hospital on February 15, 
1877. The sanitary condition of the hospital was at the time excel- 
lent. The patient was removed next day, but of the next 10 patients 
confined in adjoining wards, 9 were attacked with puerperal peritonitis, 
the only one who escaped being a case of abortion. But the connection 
between erysipelas and puerperal septicaemia is not limited to hospitals, 
having been often observed in domiciliary practice. Some interesting 
facts have been collected by Dr. Minor,^ who has shown that the two 
diseases have frequently prevailed together in various parts of the 
United States, and that during a recent outbreak of puerperal fever in 
Cincinnati it occurred chiefly in the practice of those physicians who 
attended cases of erysipelas. Many children also died from erysipelas 
whose mothers had died from puerperal fever. 

Infection from Other Zymotic Diseases. — There is good reason to 
believe that the contagium of other zymotic diseases may produce a form 
of disease indistinguishable from ordinary puerperal septici^mia, and 
presenting none of the characteristic features of the specific complaint 
from which the contagium was derived. This is admitted to be a fact 
by the majority of the most eminent British obstetricians, although it 
does not seem to be allowed by continental authorities, and it is strongly 
controverted by some writers in Great Britain. It is certainly ditticuilt 
to reconcile this with the theory of septicaemia, and we are not in a posi- 
tion to give a satisfactory explanation of it. I believe, however, that 
the evidence in favor of the possibility of puerperal septicaemia origi- 
nating in this way is too strong to be assailable. 

The scarlatinal poison is that regarding which the greatest number 
of observations have been made. Numerous cases of this kind are to 
be found scattered through our obstetric literature, but the largest num- 
ber are to be met w'xiXx in a paper by Dr. Braxton Hicks in the tweltth 
volume of the Obsfctrieal Tra)isactioiu^, and they are especiallyvaluabk^ 
from that gentleman's well-known accuracy as a clinical observer. Out 

^ j\redical Press and Cireiilar, ,lanuarv-Jnno, 1S77, p. oo9. 
^ Erysipt'las and Childbed Fever, Cinoiiiiuiti, 1874. 



606 THE PUERPERAL STATE. 

of 68 cases of puerperal disease seen in consultation, no less than 37 
were distinctly traced to the scarlatinal poison. Of these, 20 had the 
characteristic rash of the disease, but the remaining 17, although the 
history clearly proved exposure to the contagium of scarlet fever, showed 
none of its usual symptoms, and were not to be distinguished from ordi- 
nary typical cases of the so-called puerperal fever. On the theory that 
it is impossible for the specific contagious diseases to be modified by the 
puerperal state, we have to admit that one physician met with 17 cases 
of puerperal septicaemia in which, by a mere coincidence, the contagium 
of scarlet fever had been traced, and that the disease nevertheless origi- 
nated from some other source — an hypothesis so improbable that its 
mere mention carries its own refutation. 

With regard to the other zymotic diseases the evidence is not so 
strong, probably from the comparative rarity of the diseases. Hicks 
mentions one case in which the diphtheritic poison was traced, although 
none of the usual phenomena of the disease were present. I lately saw 
a case in which a lady a few days after delivery had a very serious 
attack of septicaemia without any diphtheritic symptoms, her husband 
being at the same time attacked with diphtheria of a most marked type. 
Here it would be difficult not to admit the dependence of the two dis- 
eases on the same poison. 

It is, however, certain that all the zymotic diseases may attack a 
newly-delivered woman and run their characteristic course without any 
peculiar intensity. Probably most practitioners have seen cases of this 
kind ; and this is precisely one of the points of difficulty which we 
cannot at present explain, but on which future research may be expected 
to throw some light. It seems to me not improbable that the explana- 
tion of the fact that zymotic poison may in one puerperal patient run 
its ordinary course, and in another produce symptoms of intense septi- 
caemia, may be found in the channel of absorption. It is, at any rate, 
comprehensible that if the contagium be absorbed through the skin or 
the ordinary channel it may produce its characteristic symptoms and 
run its usual course, while if brought into contact with lesions of con- 
tinuity in the generative tract it may act more in the Avay of septic poi- 
son, or with such intensity that its specific symptoms are not developed. 

It may reasonably be objected that if puerperal and surgical septicae- 
mia be identical, the zymotic poisons ought to be similarly modified 
when they affect patients after surgical operations. The subject of spe- 
cific contagium as a cause of surgical pyaemia has been so little studied 
that I do not think any one would be justified in asserting that such an 
occurrence is not possible. Fritsch of Halle and other German physi- 
cians have recently shown how elaborate antiseptic precautions in 
lying-in hospitals may prevent the origin of the disease from such 
sources. Sir James Paget in his Clinical Lectures seems to believe in 
the possibility of such modification. He says : ^^ I think it not improb- 
able that in some cases results occurring with obscure symptoms within 
two or three days after operations have been due to scarlet-fever poison, 
hindered in some way from its usual progress." Sir Spencer Wells 
informs me that he has seen cases of surgical pyaemia which he had 
reason to believe originated in the scarlatinal poison ; and his well- 



PUERPERAL SEPTICAEMIA. 007 

known success as an ovariotomist is no doubt in a great measure to be 
attributed to his extreme care in seeing that no one likely to come in 
contact with his patients has been exposed to any such source of infec- 
tion. 

Sewer Gas and Defective Sanitary Arrangements. — Exposure 
to sewer gas may, I feel sure, produce the disease. In two cases of the 
kind I had the opportunity of closely watching an untrapped drain 
opened directly into the bedroom — in one instance into a bath, in the 
other into a water-closet. Both cases were indistinguishable from the 
ordinary form of the disease, and in both improvement commenced as 
soon as the patient was removed into another room. 

In a case I saw some years ago in Notting Hill, the patient, who had 
been confined within a week, had all the symptoms of a most intense 
attack of septicaemia, but none of a diphtheritic character, while her 
husband lay in an adjoining room suffering from a diphtheritic sore 
throat. Here the waste-pipe of the bath was found to communicate 
directly with the sewer. In spite of her intense illness I had the 
patient removed to another house, and from that moment she began to 
improve. In two other cases in which the same source of disease was 
detected the removal of the patient from the infected atmosphere was 
immediately followed by a marked amelioration in the symptoms. I 
know of three similar cases which ended fatally in which I have every 
reason to believe that the cause of the disease was poisoning by sewer 
gas. Frankenhauser has related a curious case of the poisoning of four 
puerperal women by sewer gas. In fact, the whole question of defec- 
tive sanitary conditions on the puerperal state deserves much more 
serious study than it has ever yet received, and I have long been satis- 
fied that they have often much to do with certain grave forms of illness 
in the lying-in state the origin of which cannot otherwise be traced. ^ 

^ Since the above was written I have published a special paper on this subject 
("Defective Sanitation as a Cause of Puerperal Disease," Lancet, February 5, 1SS7). 
I append from it two cases, as I think the diagrams illustrating this source of danger 
may prove of interest. 

The annexed diagram (Fig. 197) represents a bedroom in a large house in the most 
fashionable part of the West End which had been recently taken and done up in the 
most costly way. I attended the lady of the house in her second confinement, and she 
lay in her bed at A. Shortly she developed well-marked septic symptoms, and I nat- 
urally investigated the sanitary state of the house to see if it threw any light on their 
origin. I could find nothing amiss. There was no bath or fixed washstand near the 
room, and the closets were at a distance, with the soil-pipe running down the outside 
wall, as it should do. It was not until some days afterward that I discovered the 
extraordinary arrangement depicted in the diagram, which no one could possibly have 
suspected, and the knowledge of which the patient had given special directions should 
be withheld from me. At i? is reprcscntcnl a very handsome and innocent-looking 
piece of f'urniture which seemed to be a tixcd wardrobe, to wiiich purpose its ends were 
in fact devoted. The centre door, however, formed by a large mirror, opened imi a 
concealed water-closet (c), which luxury no one could have looked for in such a situa- 
tion. 1 subsequently discovered that this was a brilliant idea o\' her husband's, who 
actually had iiad a special soil-pipe carried through the centre of the house which 
connnunicated directly with the main drain, with no ventilation, and who had thus 
contrived, at an enormous cost^, to have a stream o( sewer gas \i\'\d on close to his IhhI- 
side. And be it remarked tiiat builders ami plumbers had carried out tiiis ingeniously 
dangerous arrangement without giving hint the slightest hint that it was either uii- 
nsual or perilous. Of comso as soon as I made this discovery I had the patient rentoveii 
to anotlier room, when her symptoms soon abated. 



608 



THE PUERPERAL STATE. 



Septicaemia from Contag'ion Conveyed from other Puerperal 
Patients. — The last source from which septic matter may be conveyed 

I could easily go on multiplying examples of this kind, but I shall content myself 
with one more case, which was thoroughly worked out with very instructive results. 
It was that of a lady who was confined in the country of her first child, in a large and 
expensive house, newly built, and supposed to be supplied with all the most perfect 



Fig. 19 




BED ROOM 




sanitary arrangements. There was nothing particular about the labor, and for the first 
ten days the convalescence left nothing to be desired. On the eleventh day she got up 
and lay on the sofa (Fig. 198, d) opposite the fire (f), which, as it was in January, was 
burning day and night. The day after, although she had a headache and felt poorly, 
she again got up and lay on the sofa. The subsequent day, although feeling very ill, 
she again insisted on getting up, and lay on the sofa at e in her husband's dressing- 
room. On the following day she was very ill indeed, with a temperature of 104° and 
a pulse of 130, and I was summoned to see her. It is needless to say more of her ill- 
ness, which rapidly increased, except that, feeling satisfied it was caused by defective 
sanitation, I advised her removal to a house in the neighborhood, in spite of the very 
grave symptoms that existed, with the most satisfactory result, for within twenty-four 
hours her temperature had fallen and she rapidly became convalescent. Of course at 
this time nothing was known of what actually existed, but I was led to form this con- 
clusion from the fact that a number of the servants and residents were suffering from 
sore throats, and from being told that almost every one who came to stay felt ill and 
out of sorts. Subsequently the sanitary state of the house was thoroughly investigated 
by one of the most distinguished sanitary engineers in London, from whose reports the 
accompanying diagram (Fig. 198) is copied. It is useless to enter into a description 
of all the abominations which were found to exist, which, in a house of the kind, in 
the building of which no expense was spared, were almost past belief For the pur- 
pose of my story it will sufiice to say that the smoke-test showed that there was a very 
abundant escape of sewer gas into both the bedroom and dressing-room, which, from 
the fact that there were large fires burning constantly in both rooms, passed in a con- 
tinuous current in the direction of the arrows. In addition, the plumbing-work in the 
closet in the dressing-room had been so imperfectly done that its contents found their 
way out under the floor. Xow, mark how thoroughly and curiously these facts prove 
the cause of the disease. The patient lay in the bed at c, which, from the accident of 



P UERPERA L SF.PTTCJEMIA . 



600 



is from a patient suffering from puerperal septicaemia — a mode of origin 
which has of late attracted special attention. That this is the explana- 
tion of the occasional endemic prevalence of the disease in lying-in 
hospitals can scarcely be doubted. The theory of a special j)uerperal 
miasm pervading the hospital is not required to account for the facts, 
for there are a hundred ways impossible to detect or avoid — on the 
hands of nurses or attendants, in sponges, bed-pans, sheets, or even 
suspended in the atmosphere — in which septic material derived from 
one patient may be carried to another. 

The poison may be conveyed in the same manner from one private 
patient to another. Of this tliere are many lamentable instances % 
recorded. Thus it was mentioned by a gentleman at the recent discus- 
sion at the Obstetrical Society that 5 out of 14 women he attended 
died, no other practitioner in the neighborhood having a case. This 



its being winter and the current of sewer gas being drawn therefore to the chimneys, 
was quite out of its reach, and for the first ten days after her confinement, while she 
remained in bed, she was perfectly well. On the eleventh day, when she got up, she 
was placed directly in the current of sewer gas at d, and instantly got poisoned. On 
the twelfth and thirteenth days she was again exposed to the absorption of further and 

Fig. 198. 




inore intense poisoning, while imuiodiately on her removal lo frosh and unoontam- 
ninted air all her throatoning symptoms (lisap{varod. Komark also that ihoro'was 
nothing peculiar in the symi)toma(oK\uv, nothing diU'oront iVom an ordinary and rai>- 
idly progressing case of puerperal sopticicmia. It seems to mo that this instructive 
Jii.story is about as ci>mplete a dennMistration o'[ tlie origin oi puerperal disease from 
defective sanitation as any one could possibly desire, and" 1 can see no llaw iu the ciiain 
of evidence. 

39 



610 THE PUERPERAL STATE. 

origin of the disease was clearly pointed out by Gordon^ toward the 
end of last century, who stated that he himself " was the means of car- 
rying the infection to a great number of women/' and he also traced 
the spread of the disease in the same way in the practice of certain 
midwives. In some remarkable instances the unhappy property of 
carrying contagion has clung to individuals in a Avay which is most 
mysterious, and which has led to the supposition that the whole system 
becomes saturated with the poison. One of the strangest cases of this 
kind was that of Dr. Rutter of Philadelphia, which caused much dis- 
cussion. He had 45 cases of puerperal septicaemia in his own practice 
in one year, while none of his neighbors' patients were attacked. Of 
him it is related: ''Dr. Rutter, to rid himself of the mysterious 
influence which seemed to attend upon his practice, left the city for ten 
days, and before waiting on the next parturient case had his hair 
shaved off and put on a wig, took a hot bath, and changed every arti- 
cle of his apparel, taking nothing with him that he had worn or carried 
to his knowledge on any former occasion ; and mark the result ! The 
lady, notwithstanding that she had an easy parturition, was seized the 
next day with childbed fever, and died on the eleventh day after the 
birth of the child. Two years later he made another attempt at self- 
purification, and the next case attended fell a victim to the same dis- 
ease." No wonder that Meigs, in commenting on such a history, refused 
to believe that the doctor carried the poison, and rather thought ''that 
he was merely unhappy in meeting with such accidents through God's 
providence." It appears, however, that Dr. Rutter was the subject of 
a form of ozsena; and it is quite obvious that under such circumstances 
his hands could never have been free from septic matter.^ This obser- 
vation is of peculiar interest as showing that the sources of infection 
may exist in conditions difflcult to suspect and impossible to obviate, and 
it affords a satisfactory explanation of a case which was for years consid- 
ered puzzling in the extreme. It is quite possible that other similar 
cases, of w^hich many are on record, although none so remarkable, may 
possibly have depended on some similar cause personal to the medical 
attendant. 

The sources of septic poison being thus multifarious, a few words may 
be said as to the mode in which it may be conveyed to the patient. 

Mode in which the Poison may be Conveyed to the Patient. — 
As on the view of puerperal septicaemia which seems most to agree 
with recorded facts, the poison, from whatever source it maybe derived, 
must come into actual contact with lesions of continuity in the genera- 
tive tract, it is obvious that one method of conveyance may be on the 
hands of the accoucheur. That this is a possibility, and that the dis- 

^ See Lecturea on Puerperal Fever, by Robert J. Lee, M. D. 

'■' This is stated on the authority of an obstetrical contemporary of Dr. Eiitter. (See 
Amer. Jnurn. of Med. Science, 1875, vol. Ixix. p. 474 (Minor).) 

The author quotes from the editor. Dr. Eutter had an ozpena which in time much 
disfigured him from its efiect upon the contour of his nose. He was unfortunately 
inoculated in his index finger from a patient, and neglected the pustule. He had 95 
cases of puerperal septicaemia in four years and nine months, Avith 18 deaths. The 
question of Dr. Meigs, who was a non-contagionist in regard to puerperal peritonitis, 
was remarkably apposite r " Did he distil a subtle essence which he carried with 
him ? " — Harris, note to 3d American edition. 



PUERPERAL SEPTICEMIA. Oil 

ease has often been unhappily conveyed in this way, no one can doubt. 
Still, it would be unfair in the extreme to conclude that this is the only 
way in which infection may arise. In town practice especially there 
are many other ways in which septic matter may reach the patient. The 
nurse may be the means of communication, and if she have been in 
contact with septic matter she is even more likely than the medical 
attendant to convey it when washing the genitals during the first few 
days after delivery, the time that absorption is most apt to occur. 
Barnes relates a whole series of cases occurring in a suburb of London 
in the practice of different practitioners, every one of which was 
attended by the same nurse. Again, septic matter may be carried in 
sponges, linen, and other articles. What is more likely, for example, 
than that a careless nurse might use an imperfectly washed sponge on 
which discharge has been allowed to remain and decompose? Nor do 
I see any reason to question the possibility of infection from septic 
matter suspended in the atmosphere ; and in lying-in hospitals, where 
many women are congregated together, there can be little doubt that 
this is a common origin of the disease. It is certain, whatever view 
we may take of the character of the septic material, that it must be in 
a state of very minute subdivision, and there is no theoretical difficulty 
in the assumption of its being conveyed by the atmosphere. 

Conduct of the Practitioner in Relation to the Disease. — This 
question naturally involves a reference to the duty of those who are 
unfortunately brought into contact with septic matter in any form, 
either in a patient suffering from puerperal septicaemia, zymotic disease, 
or offensive discharges. The practitioner cannot always avoid such con- 
tact, and it is practically impossible to relinquish obstetric work every 
time that he is in attendance on a case from which contagion may be 
carried. Nor do I believe, especially in these days when the use of 
antiseptics is so well understood, that it is essential. It was otherwise 
when antiseptics were not employed, but I can scarcely conceive any 
case in which the risk of infection cannot be prevented by proper care. 
The danger I believe to be chiefly in not recognizing the possible risk, 
and in neglecting the use of proper precautions. It is impossible, 
therefore, to urge too strongly the necessity of extreme and even exag- 
gerated care in this direction. The practitioner should accustom him- 
self, as much as possible, to use the left hand only in touching patients 
suffering from infectious diseases, as that which is not used, under ordi- 
nary circumstances, in obstetric manipulations. He slunild be nu>st 
careful in the frequent employment of antiseptics in washing his hands, 
such as Condy^sfluid, carbolic acid, or the 1-in-lOOO solution of perchloride 
of mercury. Clothing should be changed on leaving an infectious case. 
Much more care than is usually practised should be taken bv nui-ses, espe- 
cially in securing piM-fect cleanliness in everything brought into contact 
witli the patient. When, however, a ])ractitioner is in actual and con- 
stant attendance on a case of ])ucrperal septi(wniia, when he is visiting 
his patient many times a day, especially if he be himself washing out 
the uterus with antiseptic kUions, it is certain that he cannot dolivor 
other patients with safety, and he shoidd secure the assistance of a 
brother-[)ractitioner, although there seems no reason whv he should not 



612 THE PUERPERAL STATE. 

visit women already confined in whom he has not to make vaginal 
examinations. 

Prophylaxis of Septicsemia. — If the views here inculcated as to 
the nature of, and mode of infection in, puerperal septicaemia be cor- 
rect, it is obvious that much may be done in the way of prophylaxis. 
A perfectly aseptic management of puerperal women is practically 
impossible. In most lying-in institutions very rigid rules are now 
laid down to prevent the possibility' of infective matter being conveyed 
to the patient either on the hands of the attendants or on instruments, 
napkins, and the like, and with the most satisfactory results. As the 
risk is much greater when lying-in women are collected together, such 
precautions, which this is not the place to discuss, are absolutely indi- 
cated. They are not, however, easily applicable in ordinary private 
practice, but there are certain simple precautions which every one might 
adopt without trouble which will materially lessen the risk of septic 
poisoning. Amongst these may be indicated the use of antiseptic 
lotions, with which the practitioner and nurse should always wash their 
hands before attending any case or touching the genital organs ; the use 
of carbolized vaseline, 1 in 8, for lubricating the fingers, catheter, for- 
ceps, etc. ; syringing out the vagina night and morning with diluted 
Condy's fluid; rigid attention to cleanliness in bedding, napkins, etc. 
Precautions such as these, although they may appear to some frivolous 
and useless, indicate a recognition of danger and an endeavor to re- 
move it, and if they were generally inculcated on nurses (see note, 
p. 560) and others, might go far to prevent the occurrence of septic 
mischief. 

Nature of the Septic Poison. — As to the precise character of the septic 
poison — although of late much has been said about it, and there is good 
reason to believe that further research may throw light on this obscure 
subject — too little is known to justify any positive statement. The 
researches of Heiberg, Von Recklinghausen, Steurer, and others have 
shown that in puerperal septicaemia, as in surgical fever, erysipelas, and 
other infectious diseases, micrococci in large numbers may be traced 
passing between the muscular and connective-tissue fibres, through the 
Ivmphatics, and thus into the general circulation, and that they may be 
found in various organs and pathological products. More recently, 
Fraukel isolated from a number of cases a chain-forming micrococcus, 
which he at first regarded as specific, and named it the Streptococcus 
puerperalis. Subsequently he satisfied himself of its identity with a 
similar micro-organism in pus. AVinkel also cultivated a streptococcus 
from a case of puerperal peritonitis. It produced an erysipelatous rash 
in the ear of a rabbit, and was similar in its characters, both morpho- 
logically and in artificial cultivations, to the streptococcus found in 
erysipelas. Gushing found streptococci in endometritis diphtheritica 
and in secondary puerperal inflammation, and Baumgarten, Bumm, 
Pfannestiel, and others have recorded similar observations. Pfannestiel 
investigated four cases of puerperal septicaemia with diphtheritic endo- 
metritis and purulent peritonitis, and he concluded that a specific micro- 
organism could not be differentiated in puerperal fever. In his opinion 
the streptococci from pus, from erysipelas, and diphtheritic affections of 



PUERPERAL SEPTICJEMIA. 613 

the pharynx had all the power of setting up puerperal septicaemia. 
These observations are of much importance, as tending to confirm by 
scientific observation the intimate relation between these various forms of 
disease which has long been believed to exist. It may be taken as certain 
that streptococci bear an intimate and important relation to the disease, 
but whether they themselves form the septic matter or carry it, or 
whether they are mere accidental concomitants of the j)y8emic processes, 
it is impossible, in the present state of our knowledge, to decide. 

Channels of Diffusion. — Passing on to the channels of diffusion 
through which the septic matter may act, we have to consider its 
effects on the structures with which it is brought into contact and the 
mode in which it may infect the system at large ; and this will include 
a consideration of the pathological phenomena. 

Local chang-es consequent on the absorption of the poison are 
pretty constant, and of these we may form an intelligible idea by think- 
ing of them as similar in character and causation to those which we 
have the opportunity of studying when septic matter is applied to a 
wound open to observation, as, for exam])le, in cases of blood-poison- 
ing following a dissection wound. Distinct traces of local action are 
not of invariable occurrence, and in some of the worst class of cases, 
when the amount of septic matter is great and its absorption rapid, 
death may occur after an illness of short duration but great intensity, 
and before appreciable local changes, either at the site of absorption 
or in the system at large, have had time to develop themselves. The 
fact that puerperal fever may prove fatal without leaving any tangible 
post-mortem signs has often been pointed out, such cases most fre- 
quently occurring during the endemic prevalence of the disease in 
lying-in hospitals. There can be little doubt, however, that in such 
cases of intense septicaemia marked pathological changes exist in the 
form of alterations of the blood and degenerations of tissue, but not 
of a character which can be detected by an ordinary })ost-mortem 
examination. In the great majority of cases indications of the disease 
exist at the site of absorption. These are described by pathologists 
as identical in their character with the inflammatory oedema which 
occurs in connection with phlegmonous erysipelas. If lacerations exist 
in the cervix or vagina, they take on unhealthy action, their edges swell, 
and their surface becomes covered Avitli a yellowish coat similar in a]^pear- 
ance to diphtheritic membrane. The nuicous membrane of the uterus 
is also generally found to be affected, and in a degree varying with the 
intensity of the local septic process. There is evidence of severe 
endometritis, and very frecpiently the whole lining of the uterus is 
profoundly altered, softened, covered with jxitches of diphtheritic 
(U^posit, and it may be in a state of general necn^sis. In the severer 
cases these changes aflect the nniscular tissue o\^ the uterus, which is 
found to be swollen, soft, imperfectly contracted, and even partially 
necrosed — a condition which is likened by Heiberg to hospital gan- 
grene. The connective tissue surrounding the generative XxwcX is also 
swolkni and (XHlematous, and the inflammation may in this wav roach 
the peritoneum, aUhough periti^iitis, so often observed in puerperal 
se])ticaMnia, does not necessarily depend on the direct transmission of 



614 THE PUERPERAL STATE. 

iDflammation from the pelvic connective tissue, but it is more often a 
secondary j^henomenon. 

The channels through which general systemic infection may 
supervene are the lymphatics and the venous sinuses, the former being 
by far the most important. Recent researches have shown the great 
number and complexity of the lymphatics in connection with the pelvic 
viscera, and marked traces of the absorption of septic matter are almost 
always to be found, except in those very intense cases already alluded 
to in which no appreciable post-mortem signs are discoverable. The 
septic matter is probably absorbed from the lymph-spaces abounding in 
the connective tissue and carried along the lymphatic canals to the near- 
est glands. The result is inflammation of their coats and thrombosis of 
their contents, which may be seen on section as a creamy purulent sub- 
stance. The absorption of septic material may, as Virchow has shown, 
be delayed by the local changes produced in the lymphatics and in the 
glands with which they communicate, which are therefore conservative 
in their action : and the further progress of the case may in this way be 
stopped and local inflammation alone result, such cases being believed 
by Heiberg to be examples of abortive pyaemia. On the other hand, 
the free septic material may be too abundant and intense to be so arrested ; 
it may pass on through the lymph-canals and glands until it reaches the 
blood-current through the thoracic duct, and so produce a general blood- 
infection. This mode of absorption of septic matter, and the tendency 
of the glands to arrest its further progress, serve to explain the pro- 
gressive character of many cases in which fresh exacerbations seem to 
occur from time to time, since fresh quantities of poison, generated at 
its source of origin, may be absorbed as the case progresses. The 
uterine veins are supposed by D'Espine to be the channel of absorp- 
tion in the intense form of disease which proves fatal very shortly after 
delivery, too soon for the more gradual process of lymphatic absorption 
to have become established. It is evident that the veins are not likely 
to act in this way, since they must, under ordinary circumstances, be 
completely occluded by thrombi, otherwise hemorrhage would occur. 
If, however, uterine contraction be incomplete, the occlusion of the ven- 
ous sinuses may be imperfect, and absorption of septic material through 
them may then take place. Some Avriters have laid great stress on 
imperfect uterine contraction in predisposing to septicaemia, and its 
influence may thus be well explained. The veins may bear an import- 
ant part in the production of septicaemia, independent of the direct 
absorption of septic matter through them, by means of the detachment 
of minute portions of their occluding thrombi in the form of emboli. 
If phlegmonous inflammation occur in the immediate vicinity of the 
veins, the thrombi they contain may become infected. When once 
blood-infection has occurred by any of these channels, general sej^ti- 
csemia, the so-called puerperal fever, is developed. 

Four Principal Types of Pathological Change. — The variety of 
pathological phenomena found on post-mortem examination has had 
much to do Avith the prevalent confusion as to the nature of the dis- 
ease. This has resulted in the description of many distinct forms of 
puerperal fever, the most remarked pathological alteration having been 



PUERPERAL SEPTICEMIA. f'Ao 

taken to be the essential element of the disease. As a matter of fact, 
there is no doubt that various types of pathologic-al change are met 
with. Heiberg describes four chief classes which are by no means 
distinctly separated from one another, are often found simultaneously 
in the same subject, and are certainly not to be distinguished by the 
symptoms during life. 

Of these the first is the class of cases in which no appreciable morbid 
phenomena are found after death. This formidable and fatal form of 
the disease has long been well known, and is that described by some of 
our authors as adynamic or malignant puerperal fever. It is the variety 
which was so prevalent in our lying-in hospitals, and which Ramsbotham 
talks of as being second only to cholera in the severity and suddenness 
of its onset and in the rapidity Avith which it carried oif its victims. It 
is quite erroneous to suppose that the existence of pathological changes 
in this form of disease has never been recognized. Even with the 
coarse methods of examination formerly used, the occurrence of a fluid 
and altered state of tlie blood and ecchymoses in connection Avith vari- 
ous organs — especially the lungs^ spleen, and kidneys — were noticed and 
specially described by Copland in his Dictionary of Medicine. More 
recently it has been clearly proved by the microscope that there exist, 
in addition, the commencement of inflammation in most of the tissues, 
shown by cloudy swellings and granular infiltration and disintegration 
of the cell-elements, proving that the blood, heavily charged with septic 
matter, had set up morbid action wherever it circulated, the patient 
succumbing before this had time to develop. 

In the second type, and that perhaps most commonly met with, the 
morbid changes are more frequently found in the serous membranes, in 
the pleura, in the pericardium, but above all in the peritoneum, the 
alterations in which have long attracted notice, and have been taken 
by many writers as proving peritonitis to be the main element of the 
disease. Evidences of more or less peritonitis are very general. In the 
more severe cases there is little or no exudation of plastic lymph, such 
as is found in peritonitis unassociated with septica?mia. There is a 
greater or less quantity of brownish serum only, the coils of intestine, 
distended with flatus and highly congested, being surrounded by it. 
More often there are patchy deposits of fibrinous exudation over 
many of the viscera, the fundus uteri, the under surface of the liver, 
and the distended intestines. There is then also a considerable quantitv 
of sero-purulent fluid in the abdominal cavity. The pleural cavities 
may also exhibit similar traces of inflammatory actit^n, containino; 
imperfectly organized lymph and sero-pnrulont fluid. Schroeder states 
that pleurisy is more often the direct result of transmission of inflam- 
mation through the substance of the diaphragm or lung than a secondarv 
consequence of the septica^nia. In like manner, evidences of pericarditis 
may exist, the surface of the pericardium being highlv injected and its 
cavity containing serous fluiil. Inflammation o( the synovial mem- 
branes of the larger joints, occasionally cMuling in suppuration, is not 
uncommon, and may [)ro'l)al)ly be best included inuKu- this class o^ 
cases. 

lu the third tyi)e the nmcous membranes ap[H\u' to boar the biunt 



616 



THE PUERPERAL STATE. 



of the diseasGc The pathological changes are most marked iu the 
mucous membrane lining the intestines, which is highly congested and 
even ulcerated in patches, with numerous small spots of blood extrava- 
satecl in the submucous tissue. Similar small apoplectic effusions have 
been observed in the substance of the kidneys and under the mucous 
membrane of the bladder. Pneumonia is of common occurrence. In 
most cases it is probably secondary to the impaction of minute emboli 
in the smaller branches of the pulmonary arterv, but it may doubtless 
arise from independent inflammation of the lung-tissue, and will then 
be included in a class of cases now under consideration. 

Fig. 199. 

Name, A. S , age 30 ; confined Feb. 27, 1879 ; died March 10. 



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DAY OF 

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4TH. 


5TH. 


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The fourth class of pathological phenomena are those which are pro- 
duced chiefly by the impaction of minute infected emboli in small ves- 
sels in various parts of the body. These are the cases which most closely 
resemble surgical pyaemia both in their symptoms and post-mortem 
signs, and which by many writers are described under the name of 
'^puerperal pyaemia.^' The dependence of puerperal fever on phlebitis 
of the uterine veins was a favorite theory, and in a large proportion of 
cases the coats of the veins show signs of inflammation, their canals 
being occupied with thrombi in a more or less advanced state of disin- 
tegration. The mode in which these thrombi may become infected has 
been shown by Babnoff", who has proved that leucocytes may penetrate 



PUERPERAL SEPTICAEMIA. 



G17 



the coats of the vein, and, entering its contained coagulum, may set up 
disintegration and suppuration. This observation brings these py^emic 
forms of disease into close relation with septicaemia, such as we have 
been studying, and justifies the conclusion of Yerneuil that purulent 
infection is not a distinct disease, but only a termination of septicaemia, 
with which it ought to be studied. We have, moreover, to differentiate 
these results of embolism from those considered in a subsequent chap- 
ter, the characteristic of these cases being the infected nature of the 
minute emboli. Localized inflammations and abscesses, from the 
impaction of minute capillary emboli, are found in many parts of 

Fig. 200. 

Mrs. D , age 25; confined May 1, 1879. Puerperal septicaemia; recovery. An untrapped 

pipe, communicating with sewer, was found in bath, close to this patient's bed. 



TIME 


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DAY OF 
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DATE 


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15 





the body ; most frequently in the lungs, then in the kidneys, spleen, and 
liver, and also in the muscles and connective tissues. Pathologists are 
by no means agreed as to the invariable dependence of these on embol- 
ism, nor is it ])ossible to prove their origin from this source by post- 
mortem examination. 8ome attribute all such cMses to embolism : 
others think that they may be the results of primary sept icaMuic intlam- 
mation. It has been ])roved by Weber that minute intectod enibi>li 
may pass through the lung-capillaries; and this disputes oi' one argu- 
nu^nt against the embolic theory based on the supposed impossibility ot' 
their passage. It is probable that both caust\^ may operate, and that 



618 



THE PUERPERAL STATE. 



FiCx. 201. 

Mrs. P , age 24 ; labor natural ; confined 

May 22, 1880. A piece of decomposed 
membrane the size of hand washed out 
of her uterus at first intra-uterine injec- 
tion ; rapid recovery. 



localized inflammations occurring a short time after delivery are directly 
produced by the infected blood, while those occurring after the lapse of 
some time, as in the second or third week, depend upon embolism. 

Description of the Disease. — From what has been said as to the 
mode of infection in puerperal septicaemia, and as to the very various 
pathological changes whicli accompany it^ it will not be a matter of 
surprise to find that the symptoms are also very various in different 
cases. This can readily be explained by the amount and virulence of 
the poison absorbed, the channels of infection, and the organs which 

are chiefly implicated ; but it renders 
it very difficult to describe the dis- 
ease satisfactorily. 

The symptoms generally show^ 
themselves within two or three days 
after delivery. As infection most 
often occurs during labor, or in cases 
which are autogenetic within a short 
time afterward, and before the lesions 
of continuity in the generative tract 
have commenced to cicatrize, it can 
be understood why septicaemia rarely 
commences later than the fourth or 
fifth day. 

In the great majority of cases the 
disease begins insidiously. There are, 
generally, some chilliness and rigor, 
but by no means always, and even 
when present they frequently escape 
observation or are referred to some 
transient cause. The first symptom 
which excites attention is a rise in the 
pulse, which may vary from 100 to 
140 or more according to the severity 
of the attack, and the thermometer 
will also show that the temperature 
is raised to 102°, or in bad cases to 
104° or 106°. Still, it must be borne 
in mind that both the pulse and tem- 
perature may be increased in the puer- 
peral state from transient causes, and do not of themselves justify the 
diagnosis of septicaemia. 

In the more intense class of cases, in which the wdiole system seems 
overwhelmed with the severity of tlie attack, the disease progresses with 
great rapidity, and often without any appreciable indication of local 
complication. The pulse is very rapid, small, and feeble, varying from 
120 to 140, and there is generally a temperature of 103° to 104°. In 
the worst form of cases the temperature is steadily high, witliout marked 
remissions. (See Figs. 204, 199, and 205.) There may be little or no 
pain or tliere may be slight tenderness on pressure over the abdomen or 
uterus, and as the disease j)i'ogresses the intestines get largely. distended 



TIME 


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DATE 


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25 


26 


27 


28 



P UERPERA L SEPTICJEMIA . 



619 



with flatus, so that intense tympanites often form a most distressing 
symptom. The countenance is sallow, sunken, and has a very anxious 
expression. As a rule, intelligence is unimpaired, aiid this may be the 
case even in the worst forms of the disease and up to the period of 
death. At other times there is a good deal of low muttering delirium, 
which often occurs at night alone, and alternates with intervals of com- 
plete consciousness, but is occasionally intensified for a short time into 
a more acute form. Diarrhoea and vomiting are of very frequent occur- 
rence; by the latter dark, grumous, coffee-ground substances are ejected. 
The diarrhoea is occasionally very profuse and uncontrollable ; in mild 

Fig. 202. 

Mrs. N , age 22; confined Thursday, May 6, 1880. Forceps. Lochia from the first offensive; 

a small piece of membrane was probably left in utero. 



TIME 


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12 


13 


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15 


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cases it seems to relieve the severity ol' ihe sym})tonis. Tho longue is 
moist and loaded with sordes, but sometimes it gets dark and dry, esj>e- 
cially toward the termination of the disease. The lochia are generally 
su])})ressed or altered in character, and sometimes they have a highly 
otiensive odor, especially when the disease is autogenetii.'. Tlie breath- 
ing is hurried and panting, and tlu^ breath itself has a very character- 
istic, heavy, swei^tish odor. The setax^ion of milk is ot'ten. Inn not 
always, arrested. 

Duration. — With \\\ka\^ or less ol' these svinptoins the t'ase g(H'< on, 
and wluMi it ends latally it geiua-ally (K)es so within a week, the fatal 
termination being indicated by uunv weakness, ra}Hd, thread-like, or 



620 



THE PUERPERAL STATE. 



intertiiitteot pulse, marked delirium, great tympanites, and sometimes a 
sudden fall of temperature, until at last the patient sinks with all the 
symptoms of profound exhaustion. 

In milder cases similar symptoms, variously modified and combined, 
are present. It is seldom that two precisely similar cases are met with: 
in some the rapid, weak pulse is most marked; in others, abdominal 
distension, vomiting, diarrhoea, or delirium. 

Local complications variously modify the symptoms and course of 
the disease. The most common is peritonitis, so much so that with 
some authors puerperal fever and puerperal peritonitis are synonymous 
terms. Here the first symptom is severe abdominal pain, commencing 
at the lower part of the abdomen, where the uterus is felt enlarged and 















Mrs. - 


— 


,a 


ge2 


■) ; 


Fig. 203. 
recovery. Confined July 


26 


, 1879, 


7.40 P. M 




















TIME 


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107° 
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Q. 

NORM.TEM. 
OF BODY 

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DAY OF 
DIS. 








1ST. 


2ND. 


3RD. 


4TH. 


5TH. 


6TH. 


7TH. 


8TH. 


9TH. 


10th 


ITth 


12TH. 


13th 


4th 


15TH 


I6TH. 


17th. 




PULSE 


\78 


^ 


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:^ 


;^ 




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;:^^ 


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DATE 


26 


27 


28 


29 


30 


31 


Aug1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


1 1 


12 


13 


14 


15 



tender. As the abdominal pain and tenderness spread, the sufferings of 
the patient greatly increase, the intestines become enormously distended 
with flatus, and the breathing is entirely thoracic, in consequence of the 
upward displacement of the diaphragm and the fact that the abdominal 
muscles are instinctively kept as mucli in repose as possible. The 
patient lies on her back, with her knees drawn up, and sometimes can- 
not bear the slightest pressure of the bed-clothes. There is generally 
much vomiting, and often severe diarrhoea. The temperature generally 
ranges from 102° to 104°, or even 106°, and is subject to occasional 
exacerbations and remissions, possibly depending on fresh absorption of 



PUERPERAL SEPTICjEMIA. 



621 



septic matter. (See Figs. 200, 203, and 202.) Tlie case generally lasts 
for a week or more, the symptoms going on from bad to worse and the 
patient dying exhausted. D'Espine points out that rigors, with exacer- 
bations of the general symptoms, not unfrequently occur about the 
sixth or seventh day, which he attributes to fresh systemic infection 
from fetid pus in the peritoneal cavity. It must not be supposed that 
all these symptoms are necessarily present when the peritonitic complica- 
tion exists. Pain is especially often entirely absent, and I have seen 
cases in which post-mortem examination proved the existence of peri- 
tonitis in a very marked degree, in which pain was entirely absent. 
Sometimes the pain is only slight, and amounts to little more than ten- 
derness over the uterus. 

Fig. 204. 



Mrs. M. 


K- 


— 


-, 


age 21 ; 


nfectionbel 


ieved to be d 


lie 


to scarlatina 




Confined 


Aug 


. 5, 1878 ; 


recovery. 


TIME 


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103° 

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<ORM.TEM 
OF BODY 




































































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DAY OF 
DIS. 


1st. 


2nd. 


3R0. 


+TH. 


5TH. 


6TH. 


/TH. 


8TH. 


9TH. 


10TH. 


11th. 


12th. 


13TH. 


14TH. 


15TH 


16TH 


17TH 


ISTH 


19TH 


20TH. 


PULSE 




130 








120 




150 








lOO 


















DATE 


Aug6 


7 


8 


9 


10 


11 


12 


13 


14 


15 


16 


17 


18 


19 


20 


21 


22 


23 


24 


25 



Symptoms of other local complications are characterized by ihoir own 
Sj)ecial symptonis : thus, pneumonia by dyspiuva, cough, dulncss, etc. ; 
pericarditis l)y the characteristic rub ; pleuri.^y by duliuss on percussion ; 
kidney alloction by albuminuria and the presence of casts ; liver compli- 
cation by jaundice ; and si) on. 

Pysemic Forms of the Disease. — The coui-se of the disease is not 
always so intense and rapid, being in some cases of a nu>rc chronic clia- 
racter and lasting many weeks, llie sym[>toms in the earlv >tai:e arc 
oi'len indistinguishable fnim those already described, and it is i;cnerallv 
only after the second week that indications of purulent intection develop 
tluMusclves. Then we often have recurrent and very severe rigors, with 
marked elevations and remissions of temperature. At the same time. 



622 THE PUERPERAL STATE. 

there is generally an exacerbation of the general symptoms, a peculiar 
yellowish discoloration of the skin, and occasionally well-developed 
jaundice. Transient patches of erythema are not uncommonly 
observed on various parts of the skin, and such eruptions have often 
been mistaken for those of scarlet fever or other zymotic disease. 
Localized inflammations and suppuration may rapidly follow. 
Amongst the most common are inflammation, or even suppuration, 
of the joints — the knees, shoulders, or hips — which is preceded by 
difficulty of movement, swelling, and very acute pain. Large collec- 
tions of pus in various parts of the muscles and connective tissue are 
not rare. Suppurative inflammation may also be found in connection 
with many organs, as in the eye, in the pleura, pericardium, or lungs ; 
each of which will of course give rise to characteristic symptoms, more 
or less modified by the type of the disease and the intensity of the 
inflammation. 

Puerperal Malarial Fever. — There is a peculiar form of febrile 
disturbance which sometimes occurs in the puerperal state, and which 
is apt to be confounded with septicaemia, to which attention has recently 
been specially directed by Fordyce Barker ^ under the name of '^ puer- 
peral malarial fever." It is specially apt to be met with in women 
w^ho have been exposed to malarial poison during their former lives, 
the recurrence of the fever being probably determined by the puer- 
peral state. Of this I have seen several very w^ell-marked examples 
in ladies who have formerly contracted fever and ague in India. One 
of vmy patients, who has long been in India and suflered from inter- 
mittent fever for years, is invariably attacked with it after delivery, 
and herself warned me of the fact the first time I attended her. The 
diagnosis is not always easy. Barker insists on the fact that puerperal 
malarial fever generally commences after thei fifth day from delivery, 
while septicaemia almost always does so before that time. In the 
malarial fever, moreover, the intermissions are much more marked, 
while there are frequently recurring chills or rigors; which is not 
the case in septicaemia. 

Treatment. — In considering the all-important subject of treatment 
the views of the practitioner are naturally biassed by the theory he has 
adopted of the nature of the disease. If that here inculcated be correct, 
the indications we have to bear in mind are — 1st, to discover, if possible, 
the source of the poison, in the hope of arresting further septic absorp- 
tion ; 2dly, to keep the patient alive until the effects of the poison are 
worn "off; and 3dly, to treat any local complication that may arise. 

The first is likely to be of great importance in cases of self-infection, 
as fresh quantities of septic matter may be from time to time absorbed. 
We, fortunately, are in possession of a powerful means of preventing 
further absorption by the application of antiseptics to the interior of the 
uterus and to the canal of the vagina. This is especially valuable 
when the existence of decomposing coagula or other sources of septic 
matter is suspected in the uterine cavity or when offensive discharges 
are present. Disinfection is readily accomplished by washing out the 
uterine cavity at least twice daily by means of a Higginson syringe 

1 ''Puerperal Malarial Fever," Amer. Journ. of Obstet., 1880, vol. xiii, p. 271. 



PUERPERAL SEPTICAEMIA. 



623 



with a long vaginal pipe attached/ The results are sometimes very 
remarkable, the threatening symptoms rapidly disappearing, and the 

Fig. 205. 

Mrs. B , age 29 ; confined March 29 ; died April 7, 1879. 



TIME 


M 


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M 


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M 


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't 103° 

I 

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1 102° 

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2 700 

H 

99 

NORM.TEM 
OF BODY 






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- 1 


DAY OF 
DIS, 




1ST. 


2ND. 


3RD. 


4th. 


5TH. 


6th. 


7TH. 


8TH. 


9TH, 


PULSE 




104>\ 


^ 


\125 


^ 


\ 


\ 


\ 


\ 


:>. 


DATE 


Mr29 


30 


31 


Apr.l 


2 


3. 


4 


5 


6 


7 



temperature and pulse falling so soon after the use of the antiseptic 
injections as to leave no doubt of the beneficial eifects of the treatment. 
I cannot better illustrate the advantages of this treatment than by the 
temperature chart (Fig. 207), which is from a case which came under 
my observation in the outdoor practice of King's College Hospital. 
It was that of a healthy woman, thirty-six years of age, who liad an 
easy and natural labor. Nothing remarkable Avas observed until the 
third day after delivery, when the temperature was found to be slightly 
increased. On the morning of the eighth day the temperature IkuI 

^ My colleague, Dr. Hayes, has invented a silver tube for the purpose ot' achninistor- 
ingsuch intra-uterine injections (Fig. 206), which answers its pur]iose admirably. The 

Fig. 200. 




numerous apertures at its extremity allow of a number oi minute streams of tluid being 
thrown out in the form o'i a spray mer the interior <>{ the uterus, the complete bathing of 
its surface and washing out of its cavity being thus ensured. It is. moreover, introdiu^i 
more easily than the cwdinary vaginal pipe, and can be aitacluHl to a lligginson syringe. 



624 



THE PUERPERAL STATE. 



risen to 105.8°. She was delirious, with a raj^id thready pulse, clammy 
perspiration, tympanitic abdomen, and her general condition indicated 
the most urgent danger. On yaginal examination a piece of com- 
pressed and putrid placenta was found in the os. This was removed 
by my colleague, Dr. Hayes, and the uterus thoroughly washed out 
with Condy's fluid and water. The same evening the temperature had 
sunk to 99° and the general symptoms were much improved. The 
next day there was a slight return of offensive discharge and an aggra- 
vation of the symptoms. After again w^ashing out the uterus the tem- 
perature fell, and from that date the patient convalesced without a 
single bad symptom. (See also Fig. 201.) 

This is a very well-marked example of the value of local antiseptic 
treatment, and I have seen many cases of the same kind. It should 
therefore never be omitted in all cases in which self-infection is possible ; 
and, indeed, even when there is no reason to suspect the presence of a 
local focus of infection the use of antiseptic lotions is advisable as a 

matter of precaution, since it can do no 
Fig- 207. harm and is generally comforting to the 

patient. Various antiseptics may be 
used, such as a weak solution of carbolic 
acid, 1 in 50, tincture of iodine dropped 
into w^arm water until it has a pale sherry 
color, Condy's fluid largely diluted, or a 
solution of perchloride of mercury of 
the strength of 1 in 2000. Of these, 
the perchloride-of-mercury solution is 
the most effective germicide, and Koch's 
experiments have conclusively proved 
that it is the only recognized antiseptic 
which can be relied upon for destroying 
the spores of micro-organisms after a single application. [Solution of 
the biniodide of mercury, 1 part to 4000, has been fully tested as a ger- 
micide in this country, Eussia, France, and Italy, and has been pro- 
nounced a less poisonous and more pow^erful antiseptic than corrosive 
sublimate by several careful observers : it is also less irritating. By 
the addition of iodide of potassium it is made readily soluble. (See 
paper by Dr. Eugene P. Bernardv of Philadelphia in Trans. Count}/ 
3Ied. Soc. Fhila., for Jan. 23, 1889.)— Ed.] As, however, there is a 
possibility that a too free and incautious use of the corrosive sublimate 
might prove poisonous, it would be well that such intra-uterine injec- 
tions should not be stronger than 1 in 2000, and that they should be 
practised by the medical man himself, the quantity for such irrigation 
not exceeding two quarts.^ One or other of these may be advantage- 
ously used alternately — one in the morning, the other in the evening. 
Occasionally I have employed a l-in-50 solution of carbolic acid, wdth 
about 5 grs. to the ounce of iodoform suspended in it. This has the 
advantage of not only being a powerful antiseptic, but of acting more 
continuously, in consequence of the powdered iodoform remaining 

^ HerfF, "Ueber Ursachen und Verhiitung der Sublimat-Vergiftung, etc.," Arch./. 
Gyndk., 1885, Bd. xxv. S. 487. 




PUERPERAL SEPTICAEMIA. 625 

partially attached to the uterine walls; or, as some have advised, an 
iodoform bougie ^ may be placed in the uterine cavity or powdered 
iodoform insufflated through the cervix. Tlie nozzle of the syringe 
should be guided well tlirough the cervix, and the cavity of the uterus 
thoroughly washed out until the fluid that issues from the vagina is no 
longer discolored. As the os is always patulous, there is no risk of 
producing the troublesome symptoms of uterine colic which occasion- 
ally follow the use of intra-uterine injections in the un impregnated 
state. It is quite useless to entrust the injection to the nurse, and it 
should be performed at least twice daily by the practitioner himself 
in all cases in which the discharges are offensive. It is not advisable, 
however, that such injections should be Used indiscriminately, since 
they are not entirely free from risk, nor should they be continued for 
more than a few days. It has been pointed out ^ that sometimes the 
intra-uterine injection itself produces rigors and other nervous troubles. 
I am certain that this observation is correct, and I have myself more 
than once seen a severe rigor rapidly follow its administration. The 
vulva should in all cases be carefully inspected, with the view of ascer- 
taining if the source of infection be not some local slough or necrotic 
ulcer about the perineum or orifice of the vagina, in which case its 
surface should be freely covered with iodoform. I have seen more 
than one instance in which this simple procedure has sufficed to cut 
short symptoms of a very threatening character. 

In a disease characterized by so marked a tendency to prostration the 
importance of sustaining the vital powers by an abundance of easily 
assimilated nourishment cannot be overrated. Strong beef-tea or other 
forms of animal soup, milk alone or mixed either with lime or soda- 
water, and the yolk of eggs beat up with milk and brandy, should be 
given at short intervals and in as large quantities as the patient can be 
induced to take ; and the value of thoroughly efficient nursing will be 
especially apparent in the management of this important part of tlie 
treatment. As there is frequently a tendency to nausea, the patient may 
resist the administration of food, and the resources of the practitioner 
will be taxed in administering it in such form and variety as will prove 
least distasteful. Generally speaking, not more than one or two hours 
should be allowed to elapse without some nutriment being given. The 
amount of stinudant required will vary with the intensity of the symp- 
toms and the indications of debility. Generally, stimulants are well 
borne, prove decidedly beneficial, and require to be given prettv froelv. 
In cases of moderate severity a tablespoonful of good old brandv or 
whiskey every four hours may suffice; but when the pulse is very rapid 
and thready, when there is nuich low delirium, tympanites, or sweat- 
ing (indicating profound exhaustion), it may be advisable to give them 
in nmch larger quantities and at shorter intervals. The careful prac- 
titioner will closely watch the etlects produced, and regulate the amount 
by the state of the patient rather than by any tixed rule; bur in severe 

' These may be made of ouni'aralno and glyoorin, about 'J.\ iiiobos in lonctli. oa^U 
containinj:: i)0 ,s>rains of iodi^forni. 

■^ Mangin, " Q,ueb|uos acvidonls provoqut5s par loj; injection;; Intra-utorinos," yoin\ 
Arch. iVObstet. ct dc Oyn., 1888, p. 38. 

40 



626 THE PUERPERAL STATE. 

cases eight or twelve ounces of braucly, or even more^ in the twenty- 
four hours may be given with decided benefit. 

Venesection, both general and local, was long considered a sheet- 
anchor in this disease. Modern views are, however, entirely opposed to 
its use; and in a disease characterized by so profound an alteration of 
the blood and so much prostration it is too dangerous a remedy to 
employ, although it is possible that it might alleviate temporarily the 
severity of some of the symptoms, especially in cases in which peritoni- 
tis is well marked and much local pain and tenderness are present. 

The rational indications in medicinal treatment are to lessen the force 
of the circulation as much as is possible without favoring exhaustion 
and to diminish the temperature. 

For the former purpose Barker strongly advocates the use of the 
tincture of veratrum viride, in doses of five drops every hour, until the 
pulse falls to below 100, when its effects are subsequently kept up by 
two or three drops every second hour. Of this drug I have no per- 
sonal experience, but I have extensively used minute doses of tincture 
of aconite for the same purpose, and when carefully given I believe it 
to be a most valuable remedy. The way I have administered it is to 
give a single drop of the tincture, at first every half hour, increasing 
the interval of administration according to the effect produced. Gener- 
ally, after giving four or five doses at intervals of half an hour, the 
pulse begins to fall, and afterward a few doses at intervals of one or tAvo 
hours will suffice to prevent the heart's action rising to its former rapid- 
ity. The advantage of thus modifying cardiac action with the view of 
preventing excessive waste of tissue cannot be questioned. It is evi- 
dent that so powerful a remedy must not be used without the most 
careful supervision, for if continued too long or given at too frequent 
intervals it may unduly depress the circulation and do more harm than 
good. It is necessary, therefore, that the practitioner should constantly 
watch the effect of the drug, and stop it if the pulse become very weak 
or if it intermit. It is most likely to be useful at an early stage of the 
disease before much exhaustion is present, and then only when the 
pulse is of a certain force and volume. Barker says of the veratrum 
viride, what is also true of aconite, that "it should not be given in 
those cases in Avhich rapid prostration is manifested by a feeble, thread- 
like, irregular pulse, profuse sweats, and cold extremities." 

The reduction of temperature must form an important part of our 
treatment, and for this purpose many agents are at our disposal. 

Quinine in large doses, of from 10 to 30 grains, has been much used 
for this purpose, especially in Germany. After its exhibition the tem- 
perature frequently falls one or two degrees. It may be given morning 
and evening. Unpleasant head-symptoms, deafness and ringing in the 
ears, often render its continuance for a length of time impossible. These 
may, however, be much lessened by the addition of 10 to 15 minims of 
hydrobromic acid to each dose. 

Antipyrine in doses of 20 grains every three or four hours sometimes 
proves very efficacious, but as it is apt to depress it should be combined 
with some stimulant, such as 30 minims of sal-volatile. 

Salicylic acid, in doses of from 10 to 20 grains, or the salicylate of 



PUERPERAL SEPTICAEMIA. 627 

soda in the same doses, is a valuable antipyretic which I liave found on 
the whole more manageable than quinine. Under its use the tempera- 
ture often falls considerably in a short space of time. It is, however, 
apt to depress the circulation, and thus requires to be carefully watched 
while it is being administered, and should the pulse become very small 
and feeble it should be discontinued. 

In some cases, especially when the fever has assumed a remittent 
type, I administer with marked benefit a drug which is of high repute 
in India in the worst class of malarious remittent fevers, and the almost 
marvellous effects of which in such cases I had myself witnessed in 
India many years ago. This is the so-called Warburg^s tincture, the 
value of which has been testified to by many high authorities, among 
whom I may mention Dr. Maclean of Netley, Dr. Broadbent, and Sir 
Alexander Armstrong, the director-general of the medical department 
of the navy, who informs me that it is now supplied to all Her Majesty's 
ships in the tropics, because it is found to be of the utmost value in 
cases in which quinine has little or no effect. Recently its composition 
has been made public by Dr. Maclean. The basis is quinine, in com- 
bination with various aromatics and bitters, some of which probably 
intensify its action. Be this as it may, the testimony in favor of the 
antipyretic action of the remedy is very strong. I have found its exhi- 
bition followed by a profuse diaphoresis (this being its almost invaria- 
ble effect), and sometimes a rapid amelioration of the symptoms. In 
other cases in which I have tried it, like everything else, it has proved 
of no avail. Of its use in ten malarial cases above alluded to Dr. 
Fordyce Barker says : " For nearly two years past, in those cases where 
the stomach will tolerate it, I have found Warburg's tincture much 
more effective and speedy in producing the results desired than the 
largest doses of quinine.''^ 

Cold may be advantageously tried in suitable cases. The simplest 
mode of using it is by Thornton's ice-cap, by which a current of cold 
water is kept continuously running round the head. This has been 
found of great value in pyrexia after ovariotomy, and I have also 
found it useful as a means of reducing temperature in puerperal cases. 
It is a comforting application, and gives great relief to the throbbing 
headache, which often causes much suffering. Under its use the tem- 
perature often falls two or more degrees, and it is easily continued day 
and night. 

In very serious cases, when the temperature reaches 105° and upward, 
the external application of cold to the rest of the body may be tried. 
I have elsewhere related^ a case of puerperal septicaMuia with hyper- 
pyrexia, the temperature continuously ranging over 105°, in which I 
kept the patient for eleven days nearly constantly covered with cloths 
soaked in iced water, by which means only was the temperature kept 
within moderate bounds and life preserved. But this metluxl of treat- 
ment is excessively troublesome, and is in no way curative. It is onlv 
of use in moderating the temperature when it has reached a point at 

^ Op. cit., p. '278. 

'■"'A Lecture on a Case of Puerperal Septicjoiuia. \\[i\\ Ilvporpyroxia. treateil by 
the Continuous Application of (\-)ld," Brit. Med. Jour)!., 1S77. vol. ii. p. i>S7. 



628 THE PVERPEBAL STATE. 

which it could not continue long without destroying the patient. I 
should therefore never think of employing it unless the temperatui-e 
was over 105°, and then only as a temporary expedient, requiring inces- 
sant watching, and to be desisted from as soon as the temperature has 
reached a more moderate height. It is clearly impossible to place a 
puerperal patient in a bath, as is practised in hyperpyrexia associated 
with acute rheumatism or typhoid fever. The same effect may, how- 
ever, be obtained by placing her on macintosh sheeting, or, still better, 
on a water-bed, into which cold water is run from time to time, and 
covering the body with towels soaked in iced water, which are frequently 
renewed by the attendant nurses. During the application the temper- 
ature should be constantly taken, and as soon as it has fallen to 101° 
the cold applications should be discontinued. 

Amongst other remedies which have been used is turpentine, which 
was highly thought of by the Dublin school. In cases with much t}'m- 
panitic distension and a small weak pulse it is sometimes of unquestion- 
able value, and it probably acts as a strong nervine stimulant. Given 
in doses of 15 to 20 minims rubbed up with mucilage, it can generally 
be taken in spite of its nauseous taste. 

Purgatives, diaphoretics, or even emetics, have often been employed 
as eliminants of the poison. The former are strongly recommended by 
Schroeder and other German authorities, and in England they were 
formerly amongst the most favorite remedies, and there is a general con- 
currence of opinion amongst our older writers as to their value. In 
the first volume of the Obstetrical Journal there is a paper by Mr. Mor- 
ton in which this practice is strongly advocated, and some interesting 
eases are recorded in which it apparently acted well. He administers 
calomel in doses of 3 or 4 grains with compound extract of colocynth, 
so as to keep up a free action of the bowels. It seems quite reasonable, 
when there is constipation, to promote a gentle action of the bowels by 
some mild aperient ; but, bearing in mind that severe and exhausting 
diarrhoea is a common accompaniment of the disease, I should myself 
hesitate to run the risk of inducing it artificially, especially as there is 
no proof whatever that septic matter can really be eliminated in this 
way. At the commencement of the disease, however, I have often 
given one or two aperient doses of calomel with decided benefit. 

It is possible that further research will give us some means of coun- 
teracting the septic state of the blood, and the sulphites and carbolates 
have been given for this purpose, but as yet with no reliable results. 

The tincture of the perchloride of iron naturally suggests itself, from 
its well-known effects in surgical pyaemia. In the less intense forms of 
the disease, especially when local suppurations exist, it is certainly use- 
ful, and may be given in doses of 10 to 20 minims every three or four 
hours. In very acute cases other remedies are more reliable, and the 
iron has the disadvantage of not unfrequently causing nausea or vom- 
iting. 

When restlessness, irritation, and want of sleep are prominent symp- 
toms sedatives may be required. Under such circumstances opiates may 
be given at night, and Battley's solution, nepenthe, or the hypodermic 
injection of morjihia is the form which answers best. 



PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 629 

Pain and tenderness and local complications must be treated on 
general principles. The distress from them is most experienced when 
peritonitis is well marked. Then warm and moist applications in 
the form of poultices or fomentations are very useful. Relief is 
also sometimes obtained from turpentine stupes, and when the tym- 
panites is distressing turpentine enemata are very serviceal)le. I have 
found the free application over the abdomen of the flexible collodium 
of the Pharmacopoeia decidedly useful in alleviating the suffering from 
peritonitis. 

Such are the remedies most used in this disease. It is needless to say 
that it is quite impossible to lay down fixed rules for the management 
of any individual case ; and it is obvious that if puerperal septicaemia 
be not a special and distinct disease, its judicious treatment must depend 
on the general knowledge of the attendant and on a careful study of 
the symptoms each separate case presents. 



CHAPTER yi. 

PUERPEKAL VENOUS THROMBOSIS AND EMBOLISM. 

Puerperal Thrombosis and its Results. — Under the head of 
Thrombosis we may class several important diseases connected with the 
puerperal state which have received far less attention than they deserve. 
It is only of late years that some — we may probably safely say the 
majority — of those terribly sudden deaths which from time to time 
occur after delivery liave been traced to their true cause — viz. obstruc- 
tion of the right side of the heart and pulmonary arteries from a blood- 
clot, either carried from a distance or, as I shall hope to show, formed 
m situ. Although the result and, to a great extent, the symptoms are 
identical in both, still a careful consideration of the liistory of these two 
classes of cases tends to show that in their causation thev are distinct, 
and that they ought not to be confounded. In the former we have pri- 
marily a clotting of blood in some part of the })eripheral venous sys- 
tem, and the separation of a portion of such a thrombus due to changes 
undergone during retrograde metamorphosis tending to its eventual 
absorption. In the latter \\c have a local dei)osition of fibrin, the 
resuk of l)U)od-changes consequent on ]>regnancv and the jnierperal 
state. 'V\\Q formation of such a coaguhnu in vessels the complete 
obstruction of which is incompatible with life ex[)lains the t'atal results. 
When, however, a coagulum chances to be formed in more distant parts 
of the circulation, the vital functions are not inunodiatelv interfertxl 
with, and we have otluM- pluMiomena occiu'ring, ilne to the obstruction. 
The disease known as phlegmasia doleus I shall presently attempt to 



630 THE PVERPERAL STATE. 

show is one result of blood-clot forming in periplieral vessels. But 
from the evident and tangible symptoms it produces it has long been 
considered an essential and special disease, and the general blood-dyscra- 
sia which produces it, as well as other allied states, has not been studied 
separately. I shall hope to show that all these various conditions, dis- 
similar as they at first sight appear, are very closely connected, and that 
they are in fact due to a common cause; and thus, I think, we shall 
arrive at a clearer and more correct idea of their true nature than if we 
looked upon them as distinct and separate affections, as has been com- 
monly done. I am aware that in phlegmasia dolens, the pathology of 
which has received perhaps more study than that of almost any other 
puerperal affection, something beyond simple obstruction of the venous 
system of the affected limb is probably required to account for the pecu- 
liar tense and shining swelling which is so characteristic. Whether 
this be an obstruction of the lymphatics, as Dr. Tilbury Fox and others 
have maintained with much show of reason, or whether it is some as 
yet undiscovered state, further investigation is required to show. But 
it is beyond any doubt that the important and essential part of the dis- 
ease is the presence of a thrombus in the vessels ; and I think it will not 
be difficult to prove that in its causation and history it is precisely similar 
to the more serious cases in which the pulmonary arteries are involved. 

It will be well to commence the study of the subject by a considera- 
tion of the conditions which in the puerperal state render the blood so 
peculiarly liable to coagulation, and we may then proceed to discuss the 
symptoms and results of the formation of coagula in various parts of 
the circulatory system. 

Conditions which Favor Thrombosis. — The researches of Yir- 
chow, Benjamin Hall, Humphry, Richardson, and others have rendered 
us tolerably familiar Avith the conditions which favor the coagulation of 
the blood in the vessels. These are, chiefly — 1. A stagnant or arrested 
circulation ; as, for example, when the blood coagulates in the veins 
which draw blood from the gluteal region in old and bed-ridden 
people, or, as in some forms of pulmonary thrombosis, in which the 
clots in the arteries are probably the result of obstruction in the cir- 
culation through the lung-capillaries, as in certain cases of emphysema, 
pneumonia, or pulmonary apoplexy. 2. A mechanical obstruction 
around which coagula form, as in certain morbid states of the vessels ; 
or, a better example still, secondary coagula which form around a 
travelled embolus impacted in the pulmonary arteries. 3. And most 
important of all, in which the coagulation is the result of some mor- 
bid state of the blood itself. Examples of this last condition are fre- 
quently met with in the course of various diseases, such as rheumatism 
or fever, in which the quantity of fibrin is increased and the blood itself 
is loaded with morbid material. Thrombosis from this cause is by no 
means of infrequent occurrence after severe surgical operations, especially 
such as have been attended with much hemorrhage or when the patient 
is in a weak and anaemic condition. This has been specially dwelt upon 
as a not infrequent source of death after operation by Fayrer and other 
surgeons.^ 

^ Edin. Med. Joiirn., March, 1861 ; Indian Aimals of Med., July, 1867. 



PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 631 

Coagulation in the Puerperal State. — But little consideration is 
required to show why thrombosis plays so important a part in the puer- 
peral state, for there most of the causes favoring its occurrence are pres- 
ent. Probably there is no other condition in which they exist in so 
marked a degree or are so frequently combined. The blood contains 
an excess of fibrin, which largely increases in the latter months of 
utero-gestation, until, as has been pointed out by Andral and Gavarret, 
it not unfrequently contains a third more than the average amount 
present in the non-pregnant state. As soon as delivery is completed 
other causes of blood-dyscrasia come into operation. Involution of 
the largely hypertrophied uterus commences, and the blood is charged 
with a quantity of eflFete material, which must be present in greater or 
less amount until that process is completed. It is an old observation 
that phlegmasia dolens is of very common occurrence in patients who 
have lost much blood during labor. Thus Dr. Leishman says : " In 
no class of cases has it been so frequently observed as in women whose 
strength has been reduced to a low ebb by hemorrhage either during or 
after labor ; and this no doubt accounts for the observation made by 
Merriman, that it is relatively a common occurrence after placenta 
prsevia.^' ^ An examination of the cases in which death results from 
pulmonary thrombosis shows the same facts, as in a large proportion 
of them severe post-partum hemorrhage has occurred. The exhaus- 
tion following the excessive losses so common after labor must of itself 
strongly predispose to thrombosis ; and, indeed, loss of blood has been 
distinctly pointed out by Richardson to be one of its most common ante- 
cedents. ^' There is/' he observes, " a condition which has been long 
known to favor coagulation and fibrinous deposition. I mean loss of 
blood and syncope or exhaustion during impoverished states of the 
body." 

Since, then, so many of the predisposing causes of thrombosis are 
present in the puerperal state, it is hardly a matter of astonishment 
that it should be of frequent occurrence or that it should lead to con- 
ditions of serious gravity. And yet the attention of the profession 
has been for the most part limited to a study of one only of the results 
of this tendency to blood-clotting after delivery, no doubt because of 
its comparative frequency and evident symptoms. True, the balance 
of professional opinion has lately held that phlegmasia dolens is chieflv 
the result of some morbid condition of the blood, j^roducing plugging 
of the veins; but the wider view which I am attempting to maintain, 
which would bring this disease into close relation with the more rarolv 
observed but infinitely important obstructions of the pulmonary arteries, 
has scarcely, if at all, been insisted on. Doubtless, further investigation 
will show that it is not in these parts of the venous system alone that 
j)uerperal thrombosis occurs ; but the symptoms and effects of venous 
obstruction c^lsewhere, important though they mav be, are unknown. 

Distinction between Thrombosis and Embolism. — I propose, 

then, to describe the symptoms and pathology of blood-clot in the 

right side of the heart an'd pulmonary artery. It mav be uset'ul here 

to rej^eat that this is essentially distinct from embolism oi' the same 

' Leishman, Syskm of Obshtn\\<, p. 7*20. 2d ed., 187(5. 



632 THE PUERPERAL STATE. 

parts. The latter is obstruction due to the impaction of a sepa- 
rated portion of a thrombus formed elsewhere, and for its production 
it is essential that thrombosis should have preceded it. Embolism is, 
in fact, an accident of thrombosis, not a primary affection. The con- 
dition we are now discussing I hold to be primary, precisely similar in 
its causation to the venous obstruction which in other situations gives 
rise to phlegmasia dolens. 

At the threshold of this inquiry we have to meet the objection, started 
by several who have written on this subject,^ that spontaneous coagula- 
tion of the blood in the right side of the heart and pulmonary arteries 
is a mechanical and physiological impossibility. This was the view of 
Virchow, who with his followers maintained that whenever death from 
pulmonary obstruction occurred an embolus was of necessity the start- 
ing-point of the malady and the nucleus round which secondary deposi- 
tion of fibrin took place. Virchow holds that the primary factor in 
thrombosis is a stagnant state of the blood, and that the impulse 
imparted to the blood by the right ventricle is of itself sufficient to 
prevent coagulation. It is to be observed that these objections are 
purely theoretical. Without denying that there is considerable force 
in the arguments adduced, I think that the clinical history of these 
cases strongly favors the view of spontaneous coagulation; and I 
w^ould apply to the theoretical objections advanced the argument used 
by one of their strongest upholders with regard to another disputed 
point : " Je prefere laisser la parole aux faits, car devant eux la theorie 
s'incline/^ ^ 

The anatomical arrangement of the pulmonary arteries shows how 
spontaneous coagulation may be favored in them; for, as Dr. Hum- 
phry has pointed out,^ " the artery breaks up at once into a number 
of branches wdiich radiate from it at different angles to the several parts 
of the lungs. Consequently, a large extent of surface is presented to 
the blood, and there are numerous angular projections into the currents; 
both which conditions are calculated to induce the spontaneous coagula- 
tion of the fibrin." We know also that thrombosis generally occurs in 
patients of feeble constitution, often debilitated by hemorrhage, in whom 
the action of the heart is much weakened. These facts of themselves 
go far to meet the objections of those who deny the possibility of spon- 
taneous coagulation at the roots of the pulmonary arteries. 

Results of Post-mortera Examinations. — The records of post- 
mortem examinations show also that in many of the cases the right 
side of the heart, as well as the larger branches of the pulmonary 
arteries, contained firm, leathery, decolorized, and laminated coagula, 
which could not have been recently formed. The advocates of the 
purely embolic theory maintain that these are secondary coagula 
formed round an embolus. But surely the mechanical causes which 
are sufficient to prevent spontaneous deposition of fibrin would also 
suffice to prevent its gathering round an embolus ; unless, indeed, the 
obstruction w^as sufficient to arrest the circulation altogether, when 
death would occur before there was any time for a secondary deposit. 

^ See especially Bertin, Des Embolies, p. 46 et seq. ^ Bertin, Des Emholies, p. 149. 
^ Humphry, On the Coaguladon of the Blood in the Venous System during Life. 



PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 633 

Before we can admit the possibility of embolism we must have at least 
one factor — that is, thrombosis — in a peripheral vessel from which an 
embolus can come. In many of the recorded cases nothing of the 
kind was found, and although, as is argued, this may have been over- 
looked, yet such an oversight can hardly always have been made. 

The strongest argument, however, in favor of the spontaneous origin 
of pulmonary thrombosis is one which I originally pointed out in a 
series of papers '^On Thrombosis and Embolism of the Pulmonary 
Artery as a Cause of Death in the Puerperal State.'^^ I there showed, 
from a careful analysis of 25 cases of sudden death after delivery in 
which accurate post-mortem examinations had been made, that cases of 
spontaneous thrombosis and embolism may be divided from each other 
by a clear line of demarcation, depending on the period after delivery 
at which the fatal result occurs. In 7 out of these cases there was dis- 
tinct evidence of embolism, and in them death occurred at a remote 
period after delivery ; in none before the nineteenth day. This con- 
trasts remarkably with the cases in which the post-mortem examination 
afforded no evidence of embolism. These amount to 15 out of 25, and 
in all of them, with one exception, death occurred before the fourteenth 
day, often on the second or third. The reason of this seems to be that 
in the former time is required to admit of degenerative changes taking 
place in the deposited fibrin leading to separation of an embolus; while 
in the latter the thrombosis corresponds in time, and to a great extent, 
no doubt, also in cause, to the original peripheral thrombosis from which, 
in the former, the embolus was derived. Many cases I have since col- 
lected illustrated the same .rule in a very curious and instructive way. 

Another clinical fact I have observed points to the same conclusion. 
In one or two cases distinct signs of pulmonary obstruction have shown 
themselves without proving immediately fatal, and shortly afterward 
peripheral thrombosis, as evidenced by phlegmasia dolens of one 
extremity, has commenced. Here the peripheral thrombosis obviously 
followed the central, both being produced by identical causes, and the 
order of events necessary to uphold the purely embolic theory was 
reversed. 

I hold, then, that those who deny the possibility of spontaneous 
coagulation in the heart and pulmonary arteries do so on insufficient 
grounds, and that we may consider it to be an occurrence, rare no 
doubt, but still sufficiently often met with, and certainly of sufficient 
importance, to merit very careful study. 

History. — Dr. Charles D. Meigs of Philadelphia was one of the fii-st 
to direct attention to spontaneous coagulation of the blood in the right 
side of the heart and pulmonary arteries as a cause of sudden death in 
the puerperal state. The occurrence itself, however, has been carefully 
studied by Paget, whose paper was published in 1855, four years 
before Meigs wrote on the subject.'"' It is true that none of Paget 's 
cases hap})ened after delivery, but he none the less clearly apprehended 
the nature of the obstruction. In 1855, Hecker^ attributiHl the majority 

^ LnmeU 1867. 

'^ Medko-Vhir. Trans., vol. xwii. p. \&2, ami vol. xxvlii. p. ;v'>-2 ; Pliiladclphia MoHcal 
Examiner, 1S49. '^ Dcutsi'fw KliniL ISoo. 



634 THE PUERPEBAL STATE. 

of these cases to embolism proper, and since that date most authors liave 
taken the same view, believing that spontaneous coagulation only occurs 
in exceptional cases, such as those in which, on account of some obstruc- 
tion in the lung or of the debility of the last few hours before death, coag- 
ula form in the smaller ramifications of the pulmonary arteries and 
gradually creep backward toward the heart. 

Symptoms of FuLmonary Obstruction. — The symptoms can hardly 
be mistaken, and there seems to be no essential diiference between the 
symptomatology of spontaneous and embolic obstructions, so that the 
same description will suffice for both. In a large proportion of cases 
the attack comes on with an appalling suddenness which forms one of 
its most striking characteristics. Nothing in the condition of the patient 
need have given rise to the least suspicion of impending mischief, when 
all at once an intense and horrible dyspnoea comes on : she g^sps and 
struggles for breath, tears off the coverings from her chest in a vain 
endeavor to get more air, and often dies in a few minutes, long before 
medical aid can l^e had, with all the symptoms of asphyxia. The mus- 
cles of the face and thorax are violently agitated in the attempt to oxy- 
genate the blood, and an appearance closely resembling an epileptic con- 
vulsion may be presented. The face may be either pale or deeply 
cyanosed. Thus in one case I have elsewhere recorded, which was an 
undoubted example of true embolism, Mr. Pedler, the resident accouch- 
eur at King's College Hospital, who was present during the attack, 
writes of the patient :^ ''She was suffering from extreme dyspncea, the 
countenance was excessively pale, her lips white, the face generally 
expressing deep anxiety." In another, which was probably an example 
of spontaneous thrombosis- occurring on the twelfth day after delivery, 
it is stated : '' The face had assumed a livid purple hue, which was so 
remarkable as to attract the attention both of the nurse and of her 
mother, who was with her." The extreme embarrassment of the cir- 
culation is shown by the tumultuous and irregular action of the heart 
in its endeavor to send the venous blood through the obstructed pul- 
monary arteries. Soon it gets exhausted, as shown by its feeble and 
fluttering beat. The pulse is thread-like and nearly imperceptible, the 
respirations short and hurried, btu air may be heard entering the luno-s 
freely. The intelligence during the struggle is unimpaired, and the 
dreadful consciousness of impending death adds not a little to the 
patient's sufferings and to the terror of the scene. Such is an imperfect 
account of the symptoms gathered from the record of what has been 
observed in fatal cases. It will be readily understood why, in the 
presence of so sudden and awful an attack, symptoms have not been 
recorded with the accuracy of ordinary clinical observation. 

Is Recovery Possible ? — A C[uestion of great practical interest 
which has been entirely overlooked by writers on the subject is, Have 
we any ground for supposing that there is a possibility of recovery after 
symptoms of pulmonary obstruction have developed themselves ? That 
such a result must be of extreme rarity is beyond question, but I have 
little doubt that in some few cases, entirely inexplicable on any other 
hypothesis, life is prolonged until the coagulum is absorbed and the pul- 

^ Brit Med. Journ., 1869, vol. i. p. 2S2. ^ Qf^^f^ Trans., 1S71, vol. sii. p. 194. 



PUERPERAL VENOUS THROMBOSIS ANT) EMBOLISM. G35 

monary circulation restored. In order to admit of this it is of course 
essential that the obstruction be not sufficient to prevent the passage of 
a certain quantity of blood to the lungs to carry on the vital functions. 
The history of many cases tends to show that the obstructing clot was 
present for a considerable time before death, and that it was only wlien 
some sudden exertion Avas made, such as rising from bed or the like, 
calling for an increased supply of blood which could not pass through 
the occluded arteries, that fatal symptoms manifested themselves. This 
was long ago pointed out by Paget,^ who says: "The case proves that 
in certain circumstances a great part of the pulmonary circulation may 
be arrested in the course of a week (or a few days more or less) without 
immediate danger to life or any indication of Avhat had happened.'^ 
And after referring to some illustrative cases, " Yet in all these cases 
the characters of the clots by which the pulmonary arteries were 
obstructed showed plainly that they had been a week or more in the 
process of formation.'^ If we admit the possibility of the continuance 
of life for a certain time, we must, I think, also admit the possibility, 
in a few rare cases, of eventual complete recovery. What is required 
is time for the absorption of the clot. In the peripheral venous system 
coagula are constantly removed by absorption. So strong, indeed, is 
the tendency to this that Humphry observes with regard to it, " It 
appears that the blood is almost sure to revert to its natural channel in 
process of time.''^ If, then, the obstruction be only partial, if suffi- 
cient blood pass to keep the patient alive, and a sudden supply of oxy- 
genated blood is not demanded by any exertion which the embarrassed 
circulation is unable to meet, it is not inconceivable that the patient 
may live until the obstruction is removed. 

Illustrative Cases. — Such I believe to be the only explanation of 
certain cases, some of which, on any other hypothesis, it is impossible 
to understand. The symptoms are precisely those of pulmonary obstruc- 
tion, and the description I have given above may be applied to them in 
every particular ; and after repeated paroxysms, each of which seems to 
threaten immediate dissolution, an eventual recovery takes place. What, 
then, I am entitled to ask, can the condition be if not that which I sug- 
gest ? As the question I am considering has never, so far as I am 
aware, been treated of by any other writer, I may be permitted to state 
very briefly the facts of one or two of the cases on which I found my 
argument, some of Avhich I have already published in detail else- 
where : 

K. H , delicate youns: lady. Labor easy. First oliild. Proluse post-partum 

lieinorrhane. Did well until the seventh day, diirinu- the whole of whieh siie t'elt 
weak. Same day an alarniini;- attack of ilyspmva t'aiue i>n. For several days she 
renuiinetl in a very critical ci>ndition, the sliuhtest exertion brinuing on ihe attacks. 
A slight blowing nuirnnn- heard for a tew days at the base of the heart, and then dis- 
appeared. For two months patient remained in the same state. As long as she was 
in the recumbent position she felt pretty comfortable, but any attempt at sitting up in 
bed or any unusual exertion inunediately brought on the embarrassed respiration. 
Dm-ing all this time it was found necessary to administer stimulants profusely to waul 
ofl' the attacks. Eventually , the patient recovere*! completely. 

Q. F , set. 44, mother o'i twelve ihiUlrcn. Conlineil on .July 0. (.>n the eleventh 

day she went to bed feeling well. IMicre was no swelling or discomt'ort o( any kind 

* Op. cil., p. aoS. '^ .!/(•(/.-( VuV. 7V(i;j,x\. vol. xxvii. p. 14. 



636 THE PUERPERAL STATE. 

about the lower extremities at this time. About half-past three a.m. she was sitting up 
in bed when she was suddenly attacked Avith an indescribable sense of oppression in 
the chest, and fell back in a serai-unconscious state, gasping for breath. She remained 
in a very critical condition, with the same symptoms of embarrassed respiration, for 
three days, when they gradually passed away. Two days offer the attack of phlegmasia 
dolens came on, the "leg swelled, and remained so for several months. 

This ca.se is an example of the fact I have ah^eady referred to^ of 
phlegmasia doleos coming on after the symptoms of pulmonary 
obstruction had manifested themselves, the inference being that both 
depended on similar causes operating on two distinct parts of the circu- 
latory system. 

C. H , fet. 24. Confined of her first child on August 20. 1 867. Thirty hours after 

delivery she complained of great weakness and dyspnoea. This was alleviated by the 
treatment employed, but on the ninth day, after making a sudden exertion, the dyspnoea 
returned with increased violence, and continued unabated until I saw the patient on 
September 4, fourteen days after her confinement. The following are the notes of her 
condition, made at the time of the visit : " I found her sitting on the sofa propped up 
with pillows, as she said she could not breathe in the recumbent position. The least 
excitement or talking brought on the most aggravated dyspnoea, which was so bad as 
to threaten almost instant death. Her sufferings during these paroxysms were terrible 
to witness. She panted and struggled for breath and her chest heaved with short, 
gasping respirations. She could not even bear any one to stand in front of her, wav- 
ing them away with her hand and calling for more air. These attacks were very fre- 
quent, and were brought on by the most trivial causes. She talked in a low suppressed 
voice, as if she could not spare breath for articulation. On auscultation air was found 
to enter the lungs freely in every direction, both in front and behind. Immediately 
over the site of the pulmonary arteries there was a distinct harsh, rasping murmur, 
confined to a very limited space and not propagated either upward or downward. The 
heart-sounds were feeble and tumultuous."' These symptoms led me to diagnose pul- 
monary obstruction, and I of course gave a most unfavorable prognosis, but to my great 
surprise the patient slowly recovered. I saw her again six weeks later, when her heart- 
sounds were regular and distinct and the murmur had completely disappeared. 

E. E , set. 42. was confined for the first time on Xovember 5, 1873. in the sixth 

month of utero-gestation. She had severe post-partum hemorrhage, depending on 
partially adherent placenta, which was removed artificially. She did perfectly well 
until the fourteenth day after delivery, when she was suddenly attacked with intense 
dyspnoea, aggravated in paroxysms. Pulse pretty full, 130. but distinctly intermittent. 
Air entered lungs freely. The heart's action was fluttering and irregular, and at the 
juncture of the fourth and fifth ribs with the sternum there was a loud blowing systolic 
murmur. This was certainly non-existent before, as the heart had been carefully aus- 
cultated before administering chloroform during labor. For two days the patient 
remained in the same state, her death being almost momentarily expected. On the 
21st — that is. two days after the appearance of the chest-symptoms — phlegmasia dolens 
of a severe kind developed itself in the riglit thigh and leg. She continued in the 
same state for many days, lying more or less tranquilly, but having paroxysms of the 
most intense apnoea, varying from two to six or eight in the twenty-four hours. Xo 
one who saw her in one of these could have expected her to live through it. Shortly 
after the first appearance of the paroxysms it was observed tliat the cellular tissue of 
the neck and part of the face became swollen and oedematous, giving an appearance 
not unlike that of phlegmasia dolens. The attacks were always relieved by stimulants. 
These she incessantly called for, declaring that she felt they kept her alive. During 
all this time the mind was clear and collected. Tlie pulse varied from 110 to 130; 
respirations about 60; temperature 101° to 102.5°. By slow degrees the patient seemed 
to be rallying. The paroxysms diminished in number, and after December 1st she 
never had another and the breathing became free and easy. The pulse fell to 80, and 
the cardiac murmur entirely disappeared. The patient remained, however, very weak 
and feeble, and the debility seemed to increase. Toward the second week in December 
she became delirious, and died, apparently exhausted, without any fresh chest-symp- 
toms, on the 19th of that month. No post-mortem examination was allowed. 

I liave narrated this case, although it terminated fatally, because I 
hold it to be one of the class I am considering. The death was cer- 



PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. fJ^M 

tainly not due to the obstruction, all symptoms of whicli liad dis- 
appeared, but apparently to exhaustion from the severity of the 
former illness. It illustrates, too, the simultaneous appearance of 
symptoms of pulmonary obstruction and peripheral thrombosis. The 
swelling of the neck was a curious symptom whicli has not been 
recorded in any other cases, and may possibly be a further proof of 
the analogy between this condition and phlegmasia dolens. 

Such Cases can only Depend on Pulmonary Obstruction. — Xow, 
it may of course be argued that these cases do not prove my thesis, inas- 
much as I only assume the presence of a coagulum. But I may fairly 
ask, in return, what other condition could possibly explain the symp- 
toms? They are precisely those which are noticed in death from 
undoubted pulmonary obstruction. No one seeing one of them, or 
even reading an account of the symptoms while ignorant of the result, 
could hesitate a single instant in the diagnosis. Surely, then, the infer- 
ence is fair that they depended on the same cause. In the very nature 
of things my hypothesis cannot be verified by post-mortem examina- 
tion ; but there is at least one case on record in which, after similar 
symptoms, a clot was actually found. The case is related by Dr. 
Richardson.^ It was that of a man who for weeks had symptoms 
precisely similar to those observed in the cases I have narrated. In 
one of his agonizing struggles for breath he died, and after death it 
was found '^that a fibrinous band, having its hold in the ventricle, 
extended into the pulmonary artery .^^ This observation proves to a 
certainty that life may continue for weeks after deposition of a coagu- 
lum; and, moreover, this condition was precisely what we should antici- 
pate, since of course the obstructing coagulum must necessarily be small, 
otherwise the vital functions would be immediately arrested. 

Cardiac Murmurs in Pulmonary Obstruction. — There is a svmp- 
tom noted in two of the above cases, and to a less extent in a third, 
which has not been mentioned in any account of fatal cases occurring 
after delivery — viz. a murmur over the site of the pulmonary arteries. 
It is a sign we should naturally expect, and very possibly it would be 
met with in fatal cases if attention were particularly directed to the 
point. In both these instances it was exceedingly well marked, and 
in both it entirely disappeared when the symptoms abated. The 
probability of such a nuu-mur being audible in cases of thrombosis 
of the pulmonary artery has been recognized by one of our highest 
authorities in cardiac disease, who actually observed it in a non-}nier- 
peral case. In the last edition of his work on diseases of the heart 
Dr. Walshe^ says: ^^ The only physical condition connected with the 
vessel itself would probably be systolic basic murmur following the 
course of the pulmonary main trunk and of its immediate divisions 
to the left and right of the sternum. This sign I most certainly hoard 
in an old gentleman whose life was Imnight to a sudden close in the 
course of an acute atl'ection by coagnlation in the pulmonarv artorv, 
and to a moderate extent in the right ventricle. 

Similar cases have probably been overlooked or misinterpreted. Manv 

' Clinical h:.<.<aus, p. 2'2[ d ,sV(/. 

* Walsho, ()n'Di.<iai<i\< of (Iw llfurt, 4th oJ.. ISTo. 



638 THE PUERPERAL STATE. 

seem to have been attributed to shock, in the absence of a better expla- 
nation — a condition to which they bear no kind of resemblance. 

Causes of Death. — The precise mode of death in pulmonary 
obstruction, whether dependent on thrombosis or embolism, has given 
rise to considerable difference of opinion. Virchow attributes it to 
syncope,^ depending on stoppage of the cardiac contraction. Panum,^ 
on the other hand, contests this view^, maintaining that the heart con- 
tinues to beat even after all signs of life have ceased. Certainly, 
tumultuous and irregular pulsations of the heart are prominent symp- 
toms in most of the recorded cases, and are not reconcilable with the 
idea of syncope. Panum's own theory is that death is the result of 
cerebral ansemia. Paget seems to think that the mode of death is 
altogether peculiar, in some respects resembling syncope, in others 
ansemia. Bertin, who has discussed the subject at great length, 
attributes the fatal result purely to asphyxia. The condition, indeed, 
is in all respects similar to that state, the oxygenation of the blood 
being prevented, not because air cannot get to the blood, but because 
blood cannot get to the air. The symptoms also seemed best explained 
by this theory : the intense dyspnoea, the terrible struggle for air, the 
preservation of intelligence, the tumultuous action of the heart, are 
certainly not characteristic either of syncope or anaemia. 

Post-morterQ Appearances of Clots. — The anatomical character 
of the clots seems to vary considerably. Ball, by whom they have 
been most carefully described, believes that they generally commence in 
the smaller ramifications of the arteries, extending backward toward 
the heart and filling the vessels more or less completely. Toward its< 
cardiac extremity the coagulum terminates in a rounded head, in which 
respect it resembles those spontaneously formed in the peripheral veins. 
It is non-adherent to the coats of the vessels, and the blood circulates, 
when it can do so at all, between it and the vascular walls. Such clots 
are white, dense, and of a homogeneous structure, consisting of layers 
of decolorized fibrin, firm at the periphery, where the fibrin has been 
most recently deposited, and softened in the centre, where amylaceous 
or fatty degeneration has commenced. Ball maintains that if the coag- 
ulum have commenced in the larger branches of the arteries, it must 
have first begun in the ventricle and extended into them. According 
to Humphry, the same changes take place in pulmonary as in periph- 
eral thrombi, and they may become adherent to the walls of the vessels 
or converted into threads or bands. When the obstruction is due to 
embolism, provided the case is a well-marked one and the embolus of 
some size, the appearances presented are different. We have no longer 
a laminated and decolorized coagulum with a rounded head, similar to 
a peripheral thrombus. The obstruction in this case generally takes 
place at the point of bifurcation of the artery, and w^e there meet with 
a grayish-white mass, contrasting remarkably with the more recently 
deposited fibrin before and behind it. It may be that the form of the 
embolus shows that it has recently been separated from a clot elsewhere, 
and in many cases it has been possible to fit the travelled portion to the 
extremity of the clot from which it has been broken. We may also, 

1 Gesamm. Abhandl., 1862, p. 316. '^ Virchow' s Archiv, 1863. 



PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 639 

perhaps, find that the embolus has undergone an amount of letrograde 
metamorphosis corresponding with that of the peripheral thrombus 
from which we suj^pose it to have come, but differing from that of the 
more recently deposited fibrin around it. It must be admitted, how- 
ever, that the anatomical peculiarities of the coagula will by no means 
always enable us to trace them to their true origin. In many cases 
emboli may escape detection from their smallness or from the quantity 
of fibrin surrounding them. 

Treatment. — But few words need be said as to the treatment of pid- 
monary obstruction. In a large majority of cases the fatal result so 
rapidly follows the appearance of the symptoms that no time is given 
us even to make an attempt to alleviate the patient^s sufferings. Should 
we meet with a case not immediately fatal, it seems that there are but 
two indications of treatment affording the slightest rational ground of 
hope: 

1. To keep the patient alive by the administration of stimulants — 
brandy, ether, ammonia, and the like — to be repeated at intervals cor- 
responding to the intensity of the paroxysms and the results produced. 
In the cases I have above narrated in which recovery ensued this took 
the place of all other medication. Possibly leeches or dry cupping to 
the chest might prove of some service in relieving the circulation. 

2. To enjoin the most absolute and complete repose. The object of 
this is evident. The only chance for the patient seems to be that the 
vital functions should be carried on until the coagulum has been 
absorbed, or at least until it has been so much lessened in size as to 
admit of blood passing it to the lungs. The slightest movements may 
give rise to a fatal paroxysm of dyspnoea from the increased supply of 
oxygenated blood required. It must not be forgotten that in a large 
proportion of cases death immediately followed some exertion in itself 
trivial, such as rising out of bed. Too much attention, then, cannot be 
given to this point. The patient should be absolutely still ; she should 
be fed with abundance of fluid food, such as milk, strong soups, ayd 
the like ; and she should on no account be permitted to raise herself in 
bed or attempt the slightest muscular exertion. If we are fortunate 
enough to meet with a case apparently tending to recovery, these pre- 
cautions must be carried on long after the severity of the symptoms has 
lessened, for a moment's imprudence may suffice to bring them back iu 
all their original intensity. 

Bertin,^ indeed, recommends a system of treatment very different 
from this. In the vain hope that the violent effort induced may cause 
the displacement of the impacted embolus (to which alone he attributes 
pulmonary obstruction), he recommends the administration of emetics. 
Few, I fancy, will be foiuid bold enough to attempt so hazardous a plan 
of treatment. 

Various drugs have been suggested in these cases. Richardson - 
reconnnended ammonia, a deficiency of which he at that time bolievtxi 
to be the chief cause of coagulation. He has since advised that liquor 
ammonine should be giVen in large doses, 20 minims every hour, iu the 
hope of causing solution of the deposited fibrin ; and he has stateii that 

^ Op. cit., p. 393. ■■' Heart Ditnust- liitriiui Prtynannj, \\ l!09. 



640 THE PUERPERAL STATE. 

he has seen good results from the practice. Others advise the adminis- 
tration of alkalies, in the hope that they may favor absorption. The 
best that can be said for them is that they are not likely to do much 
harm. 

Puerperal Pleuro -pneumonia. — This is, perhaps, the best place to 
mention an important but little understood class of cases which I believe 
to be less uncommon than is generally supposed. I refer to severe 
pleuro-pneumonia occurring in connection with the puerperal state, but 
not distinctly associated with septicaemia. Two carefully observed cases 
of this kind are recorded by MacDouald occurring in his practice ; I 
myself have met with three very marked examples within the past 
three years, one of which proved fatal, the other two giving rise to 
most serious illness, from which the patient recovered with difficulty. 

So far as my o^vn observation goes, there are marked peculiarities in 
such cases which clearly difPerentiate them from the ordinary course of 
pneumonia. The onset is sudden and unconnected with exposure to 
cold or other cause of lung disease ; there is no definite crisis, but a 
continuous pyrexia of moderate intensity, lasting a variable time ; and 
the physical signs differ from those of ordinary pneumonia. 

In MacDonald's cases, as well as in my own, they were peculiar in 
this respect, that there was very slight crepitation, marked rusty 
sputum, and a wooden dulness, much more intense than in ordinary 
pneumonia, extending over a large lung space, with a very slight 
entrance of air into the lung-tissue. It is also remarkable that a very 
large proportion of the cases were associated with phlegmasia doleus. 
Thus it existed in one of MacDonald's two cases, and in two out of my 
own three. Like phlegmasia dolens, moreover, the disease generally 
commenced some weeks after delivery; my own cases, for example,, 
occurred respectively fifteen, twenty-eight, and thirty-five days after 
labor. It is difficult to believe that there is not some connection between 
these two conditions ; and there is much in their peculiar history to lead 
to the belief that such forms of lung disease depend, in fact, on the 
thrombotic or embolic obstruction of the minute branches of the pul- 
monary arteries, caused by conditions similar to those which have pro- 
duced the phlebitic obstructions in the lower extremities. In the 
absence of careful post-mortem examination this hypothesis is clearly 
not susceptible of proof. MacDonald, while admitting that ^^a limited 
thrombosis of the pulmonary arteries would no doubt explain the facts 
of the cases,^^ is rather inclined to " seek the chief explanation of their 
occurrence in the alterations which the pregnant and puerperal condi- 
tions impress upon the blood and the blood vascular system.'^ 

I confess that to my mind the form.er hypothesis is not only the most 
definite, but the one which most readily explains all the peculiarities of 
these cases. I cannot, however, do more than suggest it, in the hope 
that further observations, and especially carefully conducted autopsies,, 
may throw some light on this obscure and little-studied subject. 

Treatment. — As regards treatment, it is obvious that it must be con- 
ducted on general principles, carefully avoiding over-severe measures,, 
and supporting the patient through a trial to the system that must 
necessarily be severe. 



PUERPERAL ARTERIAL THROMBOSIS AND EMBOLISM. 641 



CHAPTER yil. 
PUERPERAL ARTERIAL THROMBOSIS AND EMBOLISM. 

Arterial Thrombosis and Brabolism. — The same condition of the 
blood which so strongly predisposes to coagulation in the vessels through 
which venous blood circulates tends to similar results in the arterial sys- 
tem. These, however, are by no means so common, and do not, as a 
rule, lead to such important consequences. The subject has been but 
little studied, and almost all our knowledge of it is derived from a very 
interesting essay by Sir James Simpson.^ As I have devoted so much 
space to the consideration of venous thrombosis and embolism, I shall 
but briefly consider the effects of arterial obstruction. 

Causes. — In a considerable number of recorded cases the obstruction 
has resulted from the detachment of vegetations deposited on the car- 
diac valves, the result of endocarditis, either produced by antecedent 
rheumatism or as a complication of the puerperal state. Sometimes the 
obstruction seems to depend on some general blood-dyscrasia, similar to 
that producing venous thrombosis, or on some local change in the artery 
itself. Thus, Simpson records a case apparently produced by local 
arteritis which caused acute gangrene of both lower extremities, ending 
fatally in the third week after delivery. In other cases it has been 
attributed to coagulation following spontaneous laceration and corruga- 
tion of the internal coat of the artery. 

Symptoms. — The symptoms of puerperal arterial obstruction must 
of course vary with the particular arteries affected. Those with the 
obstruction of which we are most familiar are the cerebral, the brachial, 
and the femoral. The effects produced must also be modified by the 
size of the embolus and the more or less complete obstruction it pro- 
duces. Thus, for example, if the middle cerebral artery be blocked 
up entirely, the functions of those portions of the brain supplied by it 
will be more or less completely arrested, and hemiplegia of the oppo- 
site side of the body, followed by softening of the brain-texture, will 
probably result. If the nervous symptoms be developed gradually or 
increase in intensity after their first appearance, it may be that an 
obstruction, at first incomplete, has increased by the deposition of fibrin 
around it. So the occasional sudden supervention of blindness with 
destruction of the eyeball — cases of which are recorded by Simpson — 
not improbably depends on the occhision of the ophthalmic artery, the 
function of the organ depending on its supply thnnigh the single artery. 
The effects of obstruction of the visceral arteries in the puerperal state 
are entirely unknown, but it is far from unlikely that further investiga- 
tion may prove them to.be of great importance. In tht extremities 
arterial obstruction produces efiects which are well marked. They 

' Sdcctcd Obst. Workii, vol. i. p. b'lo. 
41 



642 THE PUERPERAL STATE. 

are classified by Simpson under the following heads: 1. Arrest of j)ulse 
heloio the site of obstruction. This has been observed to come on either 
suddenly or gradually, and if the occlusion be in one of the large 
arterial trunks it is a symptom which a careful examination will readily 
enable us to detect. 2. Increased force of pulsation in the arteries above 
the seat of obstruction. 3. Fall in the temperature of the limb. This 
is a symptom which is easily appreciable by the thermometer, and when 
the main artery of the limb is occluded the coldness of the extremity is 
well marked. 4. Lesions of motor and sensory functions, paralysis, 
neuralgia, etc. etc. Loss of power in the affected limb is often a promi- 
nent symptom, and when it comes on suddenly and is complete the main 
artery will probably be occluded. It may be diagnosed from paralysis 
depending on cerebral or spinal causes, by the absence of head-symp- 
toms, by the history of the attack, and by the presence of other indica- 
tions of arterial obstruction, such as loss of pulsation in the artery, fall 
of temperature, etc. The sensory functions in these cases are generally 
also seriously disturbed, not so much by loss of sensation as by severe 
pain and neuralgia. Sometimes the pain has been excessive, and occa- 
sionally it has been the first symptom which directed attention to the 
state of the limb. 5. Gangrene below or beyond the seat of arterial 
obstruction. Several interesting cases are recorded in which gangrene 
has followed arterial obstruction. Generally speaking, gangrene will 
not follow occlusion of the main arterial trunk of an extremity, as the 
collateral circulation becomes soon sufficiently developed to maintain its 
vitality. In many of the cases either thrombi have obstructed the 
channels of collateral circulation as well or the veins of the limb have 
also been blocked up. When such extensive obstructions occur they 
obviously cannot be embolic, but must depend on a local thrombosis, 
traceable to some general blood-dyscrasia depending on the puerperal 
state. 

Treatraent. — Little can be said as to the treatment of such cases, 
which must vary with the gravity and nature of the symptoms in each. 
Beyond absolute rest (in the hope of eventual absorption of the throm- 
bus or embolus), generous diet, attention to the general health of the 
patient, and sedative applications to relieve the local pain, there is little 
in our power. Should gangrene of an extremity supervene in a puer- 
peral patient, the case must necessarily be wellnigh hopeless. Simp- 
son, however, records one instance in which amputation was performed 
above the line of demarcation, the patient eventually recovering. 



OTHER CAUSES OF SUDDEN DEATH DURING LABOR. 643 



CHAPTER VIII. 

OTHER CAUSES OF SUDDEN DEATH DURING LABOR AND THE 
PUERPERAl> STATE. 

A LARGE number of the cases in which sudden death occurs during or 
after delivery find their explanation, as I have already pointed out, in 
thrombosis or embolism of the heart and pulmonary arteries. Prob- 
ably many cases of the so-called idiopathic asphyxia were, in fact, exam- 
ples of this accident, the true nature of which had been misunderstood. 
Besides these there are no doubt many other conditions which may lead 
to a suddenly fatal result in connection with parturition. 

Some of these are of an organic, others of a functional, nature. 

Organic Causes. — Among the former may be mentioned cases in 
which the straining efforts of the second stage of labor have produced 
death in patients suffering from some pre-existent disease of the heart. 
Kupture of that organ has probably occurred from fatty degeneration 
of its walls. Dehous^ narrates an instance in which the efforts of 
labor caused the rupture of an aneurism. Another case, from interfer- 
ence with the action of the heart in a patient who had pericardial effu- 
sion, is narrated by Ramsbotham. Dr. Devilliers relates an instance 
occurring in a young wDman during the second stage of labor. The 
heart was found to be healthy, but the lungs were intensely con- 
gested and blood was extensively extravasated all through their texture. 
This was probably caused by pulmonary congestion and apoplexy pro- 
duced by the severe straining efforts. Many cases from effusion of 
blood into the brain-substance or on its surface are on record, no doubt 
in patients who from arterial degeneration or other causes were predis- 
posed to apoplectic effusions. The so-called apoplectic convulsions, 
formerly described in most works on obstetrics as a variety of puer- 
peral convulsions, are evidently nothing more than apoplexy coming on 
during or after labor. As regards their pathology, they do not seem 
to differ from ordinary cases of apoplexy in the non-pregnant condition. 
One example is recorded of death which was attributed to rupture of the 
diaphragm from excessive action in the second stage. 

Functional Causes. — Among the causes of death which cannot be 
traced to some distinct organic lesion may be classed cases of svncope, 
shock, and exhaustion. Many instances of this kind are recorded. 
Thus in some women of susceptible nervous organization the severity 
of the suffering appears to bring on a condition similar to that pro- 
duced by excessive shock or exhaustion, which has not nutVequently 
proved fatal. Several examples of this kind have been I'ited bv 
McC^lintock.'-'' It is als(\ not unlikely that sudden synco})e sometimes 
produces a fatal result during or after labor. Most cases ot' death other- 
wise inexplicable used to be referred to this cause : but accurate autop- 

^ Dehous, Su'V (cs ^[ort^ (<ubiks. - Union J/tU, 1853. 



644 THE PUERPERAL STATE. 

sies were seldom made, and even when they were — the important effects 
of puhiionarv coagula being unknown — it is more than probable that 
the true cause of death Avas overlooked. It has been supposed that the 
sudden removal of pressure from the veins of the abdomen by the 
emptying of the gravid uterus after delivery may favor an increased 
afflux of blood into the lower parts of the body, and thus tend to an 
anaemic condition of the brain and the production of syncope. How- 
ever this may be, the possibility of its occurrence and its manifest 
danger in a recently-delivered woman are sufficient reasons for enfor- 
cing the recambent position after labor is over. In some of the cases 
the syncope was evidently produced by the patient's suddenly sitting 
upright. 

Death from Air in the Veins. — Some cases of sudden death imme- 
diately after labor seem to be due to the entrance of air into the veins. 
Six examples are cited by McClintock which were probably due to this 
cause. La Chapelle relates two. An interesting case is related by M. 
Lionet.^ In this the patient died five and a half hours after an easy 
and natural labor, the chief symptoms being extreme pallor, efforts at 
vomiting, and dyspnoea. Air was found in the heart and in the arach- 
noid veins. There can be no question that the uterine sinuses after 
delivery are nearly as well adapted as the veins of the neck for allow- 
ing the entrance of air. They are firmly attached to the muscular walls 
of the uterus, so that they gape open when that organ is relaxed, and 
it is easy to understand how air might enter. Indeed, in the post- 
mortem examination in one of the cases occurring in the practice of 
Mme. La Chapelle it is stated that '^ the uterine sinuses opened in the 
interior of the uterus by large orifices (one line and a half in diameter), 
through which air could readily be blown as far as the iliac veins, and 
vice versa.'' The condition of the uterus after delivery also enables the 
air to have ready access to the mouths of the sinuses, for the alternate 
relaxation and contraction of the uterus occurring after the placenta is 
expelled would tend to draw in the air as by a suction-pump. Hence 
an additional reason for insisting on firm contraction of the uterus, as 
this will lessen the risk of this accident. 

The precise mechanism of death from air in the veins has been a 
subject of dispute among pathologists. By Bichat^ it was referred to 
anaemia and syncope for want of blood in the vessels of the brain, which 
are occupied by air. Xysten^ attributed it to distension of the cavities 
of the heart by rarefied air, producing paralysis of its wall ; Leroy, to 
a stoppage of the pulmonary circulation and consequent want of proper 
blood-supply to the left heart ; while Leroy d'Etoilles thought it might 
depend on any of these causes or a combination of all of them. These 
and many other hypotheses on the subject have been advanced, to all 
which serious objection could be raised. The most recent theory is 
one maintained by Yirchow and Oppolzer,* and more recently by Feltz, 
which attributes the fatal results to impaction of the air-globules in the 

^ Dehous, op. cit., p. 58. - Recherche^ sur la Vie et la Mort, 1853. 

2 Xysten, Recherches de Phys. et Chim. Path., 1811. 

* Kasuistic der EmboUen ; Wiener Med. Woch., 1862 ; De^ Embolies capillaires, 1868, 
and op. cit., p. 115. 



PERIPHERAL VENOUS THROMBOSIS. 645 

lesser divisions of the pulmonary arteries, where they form gaseous 
emboli, and cause death exactly in the same way as when the obstruc- 
tion depends on a fibrinous embolus. The symptoms observed in fatal 
cases closely correspond to those of pulmonary obstruction, and it is not 
unlikely that some cases attributed to other causes may really depend on 
the entrance of air through the uterine sinuses. Such, for example, was 
most probably the explanation, of a case referred to by Dr. Graily 
Hewitt in a discussion at the Obstetrical Society.^ Death occurred 
shortly after the removal of an adherent placenta, during which, no 
doubt, air could readily enter the uterine cavity. The symptoms — viz. 
" severe pain in the cardiac region, distress as regards respiration, and 
pulselessness" — are identical with those of pulmonary obstruction. 
Dr. Hewitt refers the death to shock, which certainly does not gen- 
erally produce such phenomena. 



CHAPTER IX. 



PEEIPHERAL VENOUS THROMBOSIS— (SYN. CRURAL PHLEBITIS, 
PHLEGMASIA DOLENS, ANASARCA SEROSA, (EDEMA LACTEUM, 
WHITE LEG, ETC.). 

Peripheral Thrombosis. — We now come to discuss the symptoms 
and pathology of the conditions associated with the formation of 
thrombi in the peripheral venous system, or rather in the veins of the 
lower extremities, since too little is known of their occurrence in other 
parts to enable us to say anything on the subject. 

The most important of tliese is the well-known disease which under 
the name pJilecp lias la dolens has attracted much attention and given rise 
to numerous theories as to its nature and pathology. In des^ribino; it 
as a local manifestation of a general blood-dyscrasia, and not asau 
essential local disease, I am making an assumption as to its patholoov 
that many eminent authorities would not consider justifiable. I have, 
however, already stated some of the reasons for so doing, and I sliall 
shortly hope to show that this view is not incompatible with the most 
probable explanation of the peculiar state of the atiected limb. 

Symptoms. — The first symptom which usually attracts attention is 
severe pain in some part of the limb that is about to be affected. The 
character of t\w pain varies in different cases. In some it is extremelv 
acute, and is most felt in the neighborhood of, and along the course o\\ 
the chief venous trunks. It may begin in the groin or hip and extend 
downward, or it may commence in the calf and proceed upward towaixl 
the pelvis. The pain abates somewhat after swelling of the limb (^which 
generally begins within twenty-four hours), but it is always a distressing 

' Ohsd't. Tran,<., 18(?0. vol. x. \\ 'JS. 



646 THE PVERPERAL STATE. 

symptom, and continues as long as the acute stage of the disease lasts. 
The restlessness, want of sleep, and suffering which it produces are 
sometimes excessive. Coincident with the pain, and sometimes preced- 
ing it, more or less malaise is experienced. The patient may for a day 
or two be restless, irritable, and out of sorts, without any very definite 
cause, or the disease may be ushered in by a distinct rigor. Generally 
there is constitutional disturbance, varying with the intensity of the 
case. The pulse is rapid and weak, 120 or thereabouts; the tempera- 
ture elevated from 101° to 102°, with an evening exacerbation. The 
patient is thirsty, the tongue is glazed or white and loaded, the bowels 
constipated. In some few cases, when the local affection is slight, none 
of these constitutional symptoms are observed. 

Condition of the Affected Limb, — The characteristic swelling rap- 
idly follows the commencement of the symptoms. It generally begins 
in the groin, whence it extends downward. It may be limited to the 
thigh, or the whole limb, even to the feet, may be implicated. More 
rarely it commences in the calf of the leg, extending upward to the 
thigh and downward to the feet. The affected parts have a peculiar 
appearance which is pathognomonic of the disease. They are hard, 
tense, and brawny, of a shiny white color, and not yielding on pressure 
except toward the beginning and end of the illness. The appearances 
presented are quite different from those of ordinary oedema. Wlien 
the whole thigh is affected the limb is enormously increased in size. 
Frecj^uently the venous trunks, especially the femoral and popliteal 
veins, are felt obstructed with coagula and rolling under the finger. 
They are painful when handled, and in their course more or less red- 
ness is occasionally observed. Either leg may be attacked, but the left 
more frequently than the right. There is a marked tendency for the 
disease to spread, and we often find in a case which is progressing 
apparently well a rise of temperature and an accession of febrile symp- 
toms followed by the swelling of the other limb. 

Progress of the Disease. — After the acute stage has lasted from a 
week to a fortnight the constitutional disturbance becomes less marked, 
the pulse and temperature fall, the pain abates, and the sleeplessness 
and restlessness are less. The swelling and tension of the limb now 
begin to diminish and absorption commences. This is invariably a slow 
process. It is always many weeks before the effusion has disappeared, 
and it may be many months. The limb retains for a length of time 
the peculiar icooden feeling, as Dr. Churchill terms it. Any impru- 
dence, such as a too early attempt at walking, may bring on a relapse 
and fresh swelling of the limb. This gradual recovery is by far the 
most common termination of the disease. In some rare cases suppura- 
tion may take place, either in the subcutaneous cellular tissue, the lym- 
phatic glands, or even in the joints, and death may result from exhaus- 
tion. The possibility of pulmonary obstruction and sudden death from 
separation of an embolus has already been pointed oat, and the fact 
that this lamentable occurrence has generally followed some undue 
exertion should be borne in mind as a guide in the management of 
our patient. 

Period of Commencement. — The disease usually begins within a 



PERIPHERAL VENOUS THROMBOSIS. 647 

short time after delivery, rarely before the second week. In 22 cases 
tabulated by Dr. Robert Lee, 7 were attacked between the fourth and 
twelfth days, and 14 after the second week. Some cases have been 
described as commencing even months after delivery. It is question- 
able if these can be classed as puerperal, for it must not be forgotten 
that phlegmasia dolens is by no means necessarily a puerperal disease. 
There are many other conditions which may give rise to it, all of them, 
however, such as produce a septic and hyperinosed state of the 1^1 ood, 
such as malignant disease, dysentery, phthisis, and the like. My own 
experience would lead me to think that cases of this kind are much 
more common than is generally believed. [I have seen two attacks, 
several years apart and in different legs, in a male subject. — Ed.] 

History and Patholog-y. — The disease has long attracted the atten- 
tion of the profession. Passing over more or less obscure notices by 
Hippocrates, De Castro, and others, we find the first clear account in 
the writings of Mauriceau, who not only gave a very accurate descrip- 
tion of its symptoms, but made a guess at its pathology which was cer- 
tainly more happy than the speculations of his successors : it is, he says, 
caused ^^ by a reflux on the parts of certain humors which ought to 
have been evacuated by the lochia.^' Puzos ascribed it to the arrest of 
the secretion of milk and its extravasation in the affected limb. This 
theory, adopted by Levret and many subsequent writers, took a strong 
hold on both professional and public opinion, and to it we owe many of 
the names by which the disease is known to this day, such as oedema 
lacteum, milk leg, etc. In 1784, Mr. White of Manchester attributed 
it to some morbid condition of the lymphatic glands and vessels of the 
affected parts ; and this or some analogous theory, such as that of rup- 
ture of the lymphatics crossing the pelvic brim, as maintained by Tyre 
of Gloucester, or general inflammation of the absorbents, as held by 
Dr. Ferrier, was generally adopted. 

It was not until the year 1823 that attention was drawn to the condi- 
tion of the veins. To Bouillaud belongs the undoubted merit of first 
pointing out that the veins of the affected limb were blocked up by 
coagula, although the fact had been previously observed by Dr. Davis 
of University College. Dr. Davis made dissections of the veins in a 
fatal case, and found, as Bouillaud had done, that they were filled with 
coagula, which he assumed to be the results of inflammation of their 
coats; hence the name of ^' crural phlebitis" which has been extensively 
adopted, instead of phlegmasia dolens. Dr. Robert Lee did nuioh to 
favor this view, and, finding that thrombi were present in the iliac and 
uterine, as well as in the femoral veins, he concluded that the phlebitis 
commenced in the uterine branches of the hypogastric veins and 
extended downward to the femorals. He j)oInted t»ut that phleg- 
masia dolens was not limited to the puerperal state, but that when it 
did occur independently of it other causes of uterine phlebitis wei\^ 
present, such as cancer of the os and cervix uteri. The inHannnatory 
theory was })retty gener{,illy received, and eviMi now is considenHl by 
many to be a sulficient explanation of {\w disease. Indeed, the tact 
that more or less thrombosis was always present couUI not be deniinl ; 
and on the supposition that thrombosis could onlv be caused bv phle- 



648 THE PUERPERAL STATE. 

bitis, as was long supposed to be the case, the inflammatory theory was 
the natural one. Before long, however, pathologists pointed out that 
thrombosis was by no means necessarily, or even generally, the result 
of inflammation of the vessels in which the clot was contained, but that 
the inflammation was more generally the result of the coagulum. 

The late Dr. Mackenzie took a prominent part in opposing the phle- 
bitic theory. He proved by numerous experiments on the lower ani- 
mals that inflammation is not sufficient of itself to produce the exten- 
sive thrombi which are found to exist, and that inflammation originat- 
ing in one part of a vein is not apt to spread along its canal, as the 
phlebitic theory assumes. His conclusion is that the origin of the dis- 
ease is rather to be sought in some septic or altered condition of the 
blood, producing coagulation in the veins. Dr. Tyler Smith ^ pointed 
out an occasional analogy between the causes of phlegmasia dolens and 
puerperal fever, evidently recognizing the dependence of the former on 
blood-dyscrasia. ^' I believe," he says, " that contagion and infection 
play a very important part in the production of the disease. I look on 
a woman attacked with phlegmasia dolens as having made a fortunate 
escape from the greater dangers of diffiise phlebitis or puerperal fever.'' 
In illustration of this he narrates the following instructive history : "A 
short time ago a friend of mine had been in close attendance on a patient 
dying of erysipelatous sore throat with sloughing, and was himself 
affected with sore throat. Under these circumstances he attended, 
within the space of twenty-four hours, three ladies in their confinements, 
all of whom were attacked with phlegmasia dolens." 

The latest important contribution to the pathology of the disease is 
contained in two papers by Dr. Tilbury Fox, published in the second 
volume of the Obstetrical Transactions. He maintained that something 
beyond the mere presence of coagula in the veins is required to produce 
the phenomena of the disease, although he admitted that to be an 
important, and even an essential, part of the pathological changes pres- 
ent. The thrombi he believed to be produced either by extrinsic or 
intrinsic causes, the former comprising all cases of pressure by tumor 
or the like ; the latter, and the most important, being divisible into the 
heads of — 

1. True inflammatory changes in the vessels, as seen in the epidemic 
form of the disease. 

2. Simple thrombus, produced by rapid absorption of morbid fluid. 

3. Virus action and thrombus conjoined, the phlegmasia dolens itself 
being the result of simple thrombus, and not produced by diseased 
(inflamed) coats of vessels; the general symptoms the result of the 
general blood-state. 

He further pointed out that the peculiar swelling of the limbs can- 
not be explained by the mere presence of oedema, from which it is 
essentially different; the white appearance of the skin, the severe neur- 
algic pain, and the persistent numbness indicating that the whole of 
the cutaneous textures, the cutis vera, and even the epithelial layer, are 
infiltrated with fibrinous deposit. He concluded, therefore, that the 
swelling is the result of oedema plus something else, that something 

^ Tyler Smith, Manual of Obstetrics, p. 538. 



PERIPHERAL VENOUS THROMBOSIS. 649 

being obstruction of the lymphatics, by which the aVjsorption of effused 
serum is prevented. The efficient cause which produces these changes 
he believes to be, in the majority of cases, a septic action originating in 
the uterus, producing a condition similar to that in which phlegmasia 
dolens arises in the non-puerperal state. 

There is no doubt much force in Dr. Fox's arguments, and it may, I 
think, be conceded tliat obstruction of the veins per se is not sufficient 
to produce the peculiar appearance of the limb. It is, moreover, certain 
that phlebitis alone is also an insufficient explanation, not only of the 
symptoms, but even of the presence of thrombi so extensive as those 
that are found. The view which traces the disease solely to inflamma- 
tion or obstruction of lymphatics is purely theoretical, has no basis of 
facts to support it, and finds now-a-days no supporters. The experi- 
ments of Mackenzie and Lee, as well as the vastly increased knowledge 
of the causes of thrombosis which the researches of modern pathologists 
have given us, seem to point strongly to the view already stated, that 
the disease can only be explained by a general blood-dyscrasia depend- 
ing on the puerperal state. It by no means follows that Ave are to con- 
sider Dr. Fox's speculations as incorrect. It is far from improbable 
that the lymphatic vessels are implicated in the production of the pecu- 
liar swelling, only we are not as yet in a position to prove it. There 
is no inherent improbability in the supposition that some morbid state 
of the blood which produces thrombosis in the veins may also give rise 
to such an amount of irritation in the lymphatics as may interfere with 
their functions, and even obstruct them altogether. The essential and 
all-important point in the pathology of the disease, however, seems 
undoubtedly to be thrombosis in the veins ; and the probability of there 
being some as yet undetermined pathological changes in addition to this 
by no means militates against the view I have taken of the intimate 
connection of the disease with other results of thrombosis in different 
vessels. 

Changes occurring* in the Thrombi. — The changes which take 
place in the thrombi all tend to their ultimate absorption. These have 
been described by various authors as leading to organization or suppu- 
ration. It is probable, however, that the appearances which have led to 
such a supposition are fallacious, and that they are really due to retro- 
grade metamorphosis of the fibrin, generally of an amylaceous or a fatty 
character. 

Detachment of Emboli. — The peculiarities of a clot that nuist favor 
detachment of an embolus are that it preseuts such a shape as admits of a 
portion floating freely in the blood-current, by the force of wliich it is 
detached and carried to its ultimate destination. When the accident has 
occurred it is often possible to recognize the peripheral thrombus from 
which the embolus has se})arated by the fact of its terminal extremity 
presenting a fleshy fractured end, instead of the rounded head natural to 
it. Sucli detachment is unlikely to occur, even when favorai by the 
shape of the clot, unless s.uflicient time have elapsed after its formation 
to admit of its softening and becoming brittle. The curitnis tact I 
have before mentioned, of true puerperal embolism occurring in the 
large majority of cases only alter the nineteenili day tVoni delivery, 



650 THE PUERPERAL STATE. 

finds a ready explaDation in this theory, which it remarkably cor- 
roborates. 

[Although crural phlebitis is a rare sequel of the Caesarean section, it 
has followed it and the Porro operation, both in this city and ]S^ew 
York, in two cases of each, three of which were seen by the writer. It 
is most likely to occur in anaemic subjects or where there has been a 
secondary destruction of tissue from injurious pressure in a long labor. 
In my experience it is most likely to show itself about the middle of 
the third week. The disease may occur in delicate men and in unmar- 
ried women. — Ed.] 

Treatment. — On the supposition that phlegmasia dolens was the 
result of inflammation of the veins of the affected limb an antiphlo- 
gistic course of treatment was naturally adopted. Accordingly, most 
writers on the subject recommended depletion, generally by the applica- 
tion of leeches along the course of the affected vessels. "We are told 
that if the pain continue the leeches should be applied a second or even 
a third time. If we admit the septic origin of the disease, we must, I 
think, see the impropriety of such a practice. The fact that it occurs 
in a large majority of cases in patients of a weakly and debilitated con- 
stitution, often in women who have suffered from hemorrhage, is a 
further reason for not adopting this routine custom. If local deple- 
tion be employed, it should be strictly limited to cases in which 
there is much tenderness and redness across the course of the veins, and 
then only in patients of plethoric habits and strong constitution. Cases 
of this kind will form a very small minority of those coming under 
our observation. 

What has been said of the pathology of the affection tends to the 
conclusion that active treatment of any kind in the hope of curing the 
disease is likely to be useless. Our chief reliance must be on time and 
perfect rest in order to admit of the thrombi and the secondary effusion 
being absorbed, while we relieve the pain and other prominent symptoms 
and support the strength and improve the constitution of the patient. 

The constant application of heat and moisture to the affected limb 
will do much to lessen the tension and pain. "Wrapping the entire 
limb in linseed-meal poultices, frequently changed, is one of the best 
means of meeting this indication. If, as is sometimes the case, the 
weight of the poultices be too great to be readily borne, we may substi- 
tute warm flannel stupes covered with oiled silk. Local anodyne appli- 
cations afford much relief, and may be advantageously used along with 
the poultices and stupes, either by sprinkling their surface freely with 
laudanum or chloroform and belladonna liniment or by soaking the 
flannels in poppy-head fomentations. It is needless to say that the 
most absolute rest in bed should be enjoined even in slight cases, and 
that the limb should be effectually guarded from undue pressure by a 
cradle or some similar contrivance. Local counter-irritation has been 
strongly recommended, and frequent blisters have been considered by 
some to be almost specific. I should myself hesitate to use blisters, as 
they would certainly not be soothing applications, and one hardly sees 
how they can be of much service in hastening the absorption of the 
effusion. 



PERIPHERAL VENOUS THROMBOSIS. 651 

During the acute stage of the disease the constitutional treatment 
must be regulated by the condition of the patient. Light but luitri- 
tious diet must be administered in abundance, such as milk, beef-tea, 
and soups. Should there be much debility, stimulants in moderation 
may prove of service. With regard to medicines we shall probably 
find benefit from such as are calculated to improve the condition of the 
blood and the general health of the patient. Chlorate of potash, with 
diluted hydrochloric acid, quinine, either alone or in combination with 
sesquicarbonate of ammonia, the tincture of the perchloride of iron, — 
are the drugs that are most likely to prove of service. Alkalies and 
other medicines which have been recommended in the hope of hasten- 
ing the absorption of coagula must be considered as altogether useless. 
Pain must be relieved and sleep procured by the judicious use of ano- 
dynes, such as Dover's powder, the subcutaneous injection of morphia, 
or chloral. Generally no form answers so well as the hypodei'mic 
injection of morphia. 

When the acute symptoms have abated and the temperature has fallen, 
the poultices and stupes maybe discontinued and the limbs swathed in 
a flannel roller from the toes upward. The equable pressure and sup- 
port thus afforded materially aid the absorption of the effusion and tend 
to diminish the size of the limb. At a still later stage very gentle 
inunctions of weak iodine ointment may be used with advantage once a 
day before the roller is applied. Shampooing and friction of the limb, 
generally recommended for the purpose of hastening absorption, should 
be carefully avoided, on account of the possible risk of detaching a 
portion of the coagulum and producing embolism. This is no merely 
imaginary danger, as the following fact narrated by Trousseau proves : 
^^A phlegmasia alba dolens had appeared on the left side in a young 
woman suffering from periuterine phlegmon. The pain having ceased, 
a thickened venous trunk was felt on the upper and internal part of 
the thigh. Rather strong pressure was being made, when ]\I. Demar- 
quay felt something yield under his fingers. A few minutes afterward 
the patient was attacked with dreadful palpitation, tumultuous cardiac 
action, and extreme pallor, and death was believed to be imminent. 
After some hours, however, the oppression ceased and the patient event- 
ually recovered. A slightly attached coagulum must have become 
separated and conveyed to the heart or pulmonary artery."^ Warm 
douches of water — of salt water if it can be obtained — may be advan- 
tageously used in the later stages of the disease, and they may l>e 
applied night and morning, the limb being bandaged in the interval. 
The occasional use of the continuous current is said to }>romoto absorp- 
tion, and would seem likely to be a serviceable remedy. 

When the patient is well enough to be moved a change of air to the 
seaside will be of value. Great caution, however, should be n\H>m- 
mended in using the limb, and it is far better not to run the risk o{ 
a relapse by any undue haste in this respect. It is well to warn the 
patient and her friends .tliat a consiilerable time nuist oi^ necessity 
elapse before the local signs of the disease have eomplotelv disap- 
peared. 

'Trousseau, Ciiniiiiw dc I'lfotil Dtctt, in Oaz. ihs Hop., 1S(h\ p. 577. 



652 THE PUERPERAL STATE. 



CHAPTER X. 

PELVIC CELLULITIS AND PELVIC PERITONITIS. 

These Diseases have been Recognized from the Earliest Times. 
— From the earliest times the occurrence after parturition of severe 
forms of inflammatory disease in and about the pelvis, frequently 
ending in suppuration, has been well known. It is only of late yeai-s, 
however, that these diseases have been made the subject of accurate 
clinical and pathological investigation, and that their true nature has 
begun to be understood. Xor is our knowledge of them as yet by any 
means complete. They merit careful study on the part of the accou- 
cheur, for they give rise to some of the most severe and protracted 
illnesses from which puerperal patients sufPej'. They are often obscure 
in their origin and apt to be overlooked, and they not rarely leave 
behind them lasting mischief. 

These diseases are not limited to the puerperal state. On the con- 
trary, many of the severest cases arise from causes altogether uncon- 
nected with childbearing. These will not be now considered, and this 
chajiter deals solely with such forms as may be directly traced to child- 
birth. 

]\Iodern researches have demonstrated that there are two distinct 
varieties of inflammatory disease met with after labor which differ 
materially from each other in many respects. In one of these the 
inflammation affects chiefly the connective tissue surrounding the 
generative organs contained within the pelvis, or extends up from 
beneath the peritoneum and into the iliac fossae. In the other it 
attacks that portion of the peritoneum which covers the pelvic viscera, 
and is limited to it. 

Variety of Nomenclature. — So much is admitted by all writers, 
but great obscurity in description, and consequent difficulty in under- 
standing satisfactorily the nature of these affections, have resulted from 
the variety of nomenclature which different authors have adopted. 

Thus the former disease has been variously described as pelvic cellu- 
litis, periuterine phlegmon, parametritis, or pelvic abscess, while the 
latter is not unfrequently called perimetritis, as contradistinguished 
from parametritis. The use of the prefix para or peri to distinguish 
cellular or peritoneal variety of inflammation, originally suggested by 
Virchow, has been pretty generally adopted in Germany, and has been 
strongly advocated in Great Britain by Matthews Duncan. It has never, 
however, found much favor with English writers, and the similarity of 
the two names is so great as to lead to confusion. I have, therefore, 
selected the terms '^ pelvic peritonitis " and '^ pelvic cellulitis,*' as con- 
veying in themselves a fairly accurate notion of the tissues mainly 
involved. 



PELVIC CELLULITIS AND PELVIC PERITONITIS. 653 

Importance of Distinguishing- the Two Classes of Cases. — The 
important fact to remember is that there exist two distinct varieties of 
inflammatory disease presenting many similarities in their course, symp- 
toms, and results, often occurring simultaneously, but in the main dis- 
tinct in their pathology and capable of being differentiated. Thomas 
compares them — and, as serving to fix the facts on the memory, the 
illustration is a good one — to pleurisy and pneumonia. " Like them,'' 
he says, ^^ they are separate and distinct, like them affect different kinds 
of structure, and like them they generally complicate each other.'' It 
might therefore be advisable, as most writers on the disease occurring 
in the non-puerperal state have done, to treat of them in two separate 
chapters. There is, however, more difficulty in distinguishing them 
as puerperal than as non-puerperal affections, for which reason, as well 
as for the sake of brevity, I think it better to consider them together, 
pointing out as I proceed the distinctive peculiarities of each. 

Seat of Disease. — When attention was first directed to this class of 
diseases the pelvic celluluar tissue was believed to be the only structure 
affected. This was the view maintained by Nonat, Simpson, and many 
modern writers. Attention was first prominently directed to the import- 
ance of localized inflammation of the peritoneum, and to the fact that 
many of the supposed cases of cellulitis were really peritonitic, by Ber- 
nutz. There can be no doubt that he here made an enormous step in 
advance. Like many authors, however, he rode his hobby a little too 
hardj and he erred in denying the occurrence of cellulitis in many cases 
in which it undoubtedly exists. 

Etiology. — The great influence of childbirth in producing these 
diseases has long been fully recognized. Courty estimates that about 
two-thirds of all the cases met with occur in connection with delivery 
or abortion, and Duncan found that out of 40 carefully observed cases 
25 were associated with the puerperal state. 

It is pretty generally admitted by most modern writers tliat both 
varieties of the disease are produced by the extension of inflammation 
from either the uterus, the Fallopian tubes, or the ovaries. This point 
has been especially insisted on by Duncan, who maintains that the dis- 
ease is never idiopathic, and is ^' invariably secondary either to mechan- 
ical injury, or to the extension of inflammation of some of the pelvic 
viscera, or to the irritation of the noxious discharges through or from 
the tubes or ovaries." 

Their intimate connection with puerperal septict^mia is also a promi- 
nent fact in the natural history of the diseases. Barker mentions a 
curious observation illustrative of this, that Avhen puerperal fever is 
endemic in the Bellevu€ Hospital in New York, cases of pelvic peri- 
tonitis and cellulitis arc also invariably met Avith. Olshauseu lias also 
remarked that in the Lying-in Hospital at Halle during the autumn 
vacation, when the patients are not attended by practitioners, and 
when, therefore, the chance of septic infection being conveyinl to them 
is k^s, these inflammations are almost always absent. .Vs inflammations 
of the lining membrane of the uterus, the vaginal mucous membrane, 
and the pelvic connective tissue are of very constant oceurreucv as 
local phenomena of se})tic absorption, the i\>nnectiou between the two 



654 THE PUERPEBAL STATE. 

classes of cases is readily susceptible of explanation. Schroeder, indeed, 
goes further and includes his description of these diseases under the head 
of " puerperal fever." They do not, however, necessarily depend upon 
it; for, although it must be admitted that cases of this kind form a large 
proportion of those met with, others unquestionably occur which cannot 
be traced to such sources, but are the direct result of causes altogether 
unconnected with the inflammation attending on septic absorption, such 
as undue exertion shortly after delivery or premature coition. jNIechani- 
cal causes may beyond doubt excite the disease in a w^oman predisposed 
by the puerperal process, but they cannot fairly be included under the 
head of puerperal fever. 

Seat of the Inflammation in Pelvic Cellulitis. — Abundance of 
areolar tissue exists in connection with the pelvic viscera, which may 
be the seat of cellulitis. It forms a loose padding between the organs 
contained in the pelvis proper, surrounds the vagina, the rectum, and 
the bladder, and is found in considerable quantity between the folds 
of the broad ligaments. From these parts it extends upward to the 
iliac fossae and the inner surface of the abdominal parietes. In any 
of these positions it may be the seat of the kind of inflammation we 
are discussing. The essential character of the inflammation is similar 
to that which accompanies areolar inflammation in other parts of the 
body. There is first an acute inflammatory oedema, followed by the 
infiltration of the areolae of the connective tissue with exudation, and 
the consequent formation of appreciable swellings. These may form 
in any part of the pelvis. Thus we may meet with them — and this 
is a very common situation — between the folds of the broad ligaments, 
forming distinct hard tumors connected with the uterus and extending 
to the pelvic walls, their rounded outlines being readily made out by 
bimanual examination. If the cellulitis be limited in extent, such a 
sw^elling may exist on one side of the uterus only, forming a rounded 
mass of varying size and apparently attached to it. At other times the 
exudation is more extensive, and may completely or partially surround 
the uterus, extending to the cellular tissue betw^een the vagina and rec- 
tum or between the uterus and the bladder. In such cases the uterus 
is imbedded and firmly fixed in dense, hard exudation. At other times 
the inflammation chiefly afl^ects the cellular tissue covering the muscles 
lining the iliac fossae. There it forms a mass easily made out by palpa- 
tion, but on vaginal examination little or no trace of the exudation can 
be felt, or only a sense of thickness at the roof of the vagina on the 
same side as the swelling. 

Seat of the Inflammation in Pelvic Peritonitis. — In pelvic peri- 
tonitis the inflammation is limited to that portion of the peritoneum 
Avhicli invests the pelvic viscera. Its extent necessarily varies with the 
intensity and duration of the attack. In some cases there may be little 
more than irritation, while more often it runs on to exudation of plastic 
material. The result is generally complete fixation of the uterus and 
hardening and swelling in the roof of the vagina, and the lymph poured 
out may mat together the surrounding viscera, so as to form swellings 
difficult, in some cases, to differentiate from those resulting from cellu- 
litis. On post-mortem examination the pelvic viscera are found exten- 



PELVIC CELLULITIS AND PELVIC PERITONITIS. 655 

sively adherent, and the agglutination may involve the coils of the 
intestine in the vicinity so as sometimes to form tumors of consider- 
able size. 

Relative Frequency of the Two Forms of Disease. — The relative 
frequency of these two forms of inflammation as puerperal affections is 
not easy to ascertain. In the non-puerperal state the peritonitic variety 
is much the more common, but in the puerperal state they very gener- 
ally complicate each other, and it is rare for cellulitis to exist to any 
great extent without more or less peritonitis. 

Symptomatology. — The earliest symptom is pain in the lower part 
of the abdomen, which is generally preceded by rigor or chilliness. The 
amount of pain varies much. Sometimes it is comparatively slight, and 
it is by no means rare to meet with patients the subjects of very con- 
siderable exudations who suflPer little more than a certain sense of 
weight and discomfort at the lower part of the abdomen. On the 
other hand, the suffering may be excessive, and is characterized by 
paroxysmal exacerbations, the patient being comparatively free from 
pain for several successive hours, and then having attacks of the most 
acute agony. Schroeder says that pain is always a symptom of perito- 
nitis, and that it does not exist in uncomplicated cellulitis. The swellings 
of cellulitis are certainly sometimes remarkably free from tenderness, and 
I have often seen masses of exudation in the iliac fossae which could 
bear even rough handling. On the other hand, although this is cer- 
tainly more often met with in non-puerperal cases, the tenderness over 
the abdomen is sometimes excessive, the patient shrinking from the 
slightest touch. The pulse is raised, generally from 100 to 120, and 
the thermometer shows the presence of pyrexia. During the entire 
course of the disease both these symptoms continue. The temperature 
is often very high, but more frequently it varies from 100^ to 104°, 
and it generally shows more or less marked remissions. In some cases 
the temperature is said not to be elevated at all, or even to be subnor- 
mal, but this is certainly quite exceptional. Other signs of local and 
general irritation often exist. Among them, and most distinctly in 
cases of peritonitis, are nausea and vomiting, and an anxious, pinched 
expression of the countenance, while the local mischief often causes 
distressing dysuria and tenesmus. The latter is especially apt to occur 
when there is exudation between the rectum and vagina which presses 
on the bowel. The passage of feces, unless in a very liquid form, may 
then cause intolerable sulfcring. 

Such symptoms may show themselves within a few days after delivery, 
and then they can barely fail to attract attention. On the other hand, 
they may not commence for some weeks after labor, and then thev are 
often insidious in their onset and apt to be overlookai. It is far from 
rare to meet with cases six weeks or more after confinement in which 
the patient complains of little beyond a feeling of malaise and discom- 
fort, and in which, on investigation, a considerable amount o^ exudation 
is detected which had previously entirely escaped observation. 

Results of Physical Examination. — On iiuroducino- the finovr into 
i\\c vagina it will be found to be hot and swollen, in some cases dis- 
tinctly oedematous, and on reaching the vaginal eul-ile-sae the existemv 



656 THE PUERPERAL STATE. 

of exudation may generally be made out. The amount of this varies 
much. Sometimes, especially in the early stage of the disease, there is 
little more than a diffuse sense of thickness and induration at either 
side of, or behind, the uterus. More generally, careful bimanual exam- 
ination enables us to detect a distinct hardening and swelling, possibly 
a tumor of considerable size, which may apparently be attached to the 
sides of the uterus and rise above the pelvic brim, or may extend quite 
to the pelvic walls. The examination should be very carefully and 
systematically conducted with both hands, so as to explore the whole 
contour of the uterus before, behind, and on either side, as well as the 
iliac fossae; otherwise a considerable exudation might readily escape 
detection. When the exudation is at all great, more or less fixity of 
the uterus is sure to exist, and is a veiy characteristic symptom. The 
womb, instead of being freely movable by the examining finger, is 
firmly fixed by the surrounding exudation, and in severe forms of the 
disease is quite encased in it. More or less displacement of the organ 
is also of common occurrence. If the swelling be limited to one side 
of the pelvis or to Douglas' space, the uterus is displaced in the oppo- 
site direction, so that it is no longer in its usual central position. 

The differential diagnosis of pelvic cellulitis and pelvic peritonitis 
cannot always be made, and indeed in many cases it is impossible, since 
both varieties of disease coexist. The elements of diiferentiation gen- 
erally insisted on are, the greater general disturbance, nausea, etc. in 
pelvic peritonitis, with an earlier commencement of the symptoms after 
labor. The swellings of pelvic peritonitis are also more teuder, with 
less clearly defined outline than those of cellulitis. When the cellulitis 
involves the iliac fossa, the diagnosis is of course easy, and then a con- 
tinuous retraction of the thigh on the affected side (an involuntary posi- 
tion assumed with the view of keeping the muscles lining the iliac fossa 
at rest) is often observed. When the inflammation is chiefly limited to 
the cavity of the pelvis, the distinction between the two classes of cases 
cannot be made with any degree of certainty. 

Terminations. — Both forms of disease may end either in resolution 
or in suppuration. In the former case, after the acute symj)toms have 
existed for a variable time — it may be for a few days only, it may be for 
many weeks — their severity abates, the swellings become less tender and 
commence to contract, become harder, and are gradually absorbed, until 
at last the fixity of the uterus disappears and it again resumes its central 
position in the pelvic cavity. This process is often very gradual. It is 
by no means rare to find a patient, even some months after the attack, 
when all acute symptoms have long disappeared, who is even able to 
move about without inconvenience, in whom the uterus is still immov- 
ably fixed in a mass of deposit or is at least adherent in some part of 
its contour. More or less permanent adhesions are of common occur- 
rence, and give rise to symptoms of considerable obscurity, which are 
often not traced to their proper source. 

Symptoms of Suppuration. — When the inflammation is about to 
terminate in suppuration the pyrexial symptoms continue, and event- 
ually well-marked hectic is developed, the temperature generally show- 
ing a distinct exacerbation at night. At the same time rigors, loss of 



PELVIC CELLULITIS AND PELVIC PEPJTONITIS. (^rjl 

appetite, a peculiar yellowish discoloration of the face, and other signs 
of suppuration show themselves. The relative frequency of this 
termination is variously estimated by authors. Duncan quotes 8im])- 
son as calculating it as occurring in half the cases of pelvic cellulitis, 
but states his own belief that it is much more frequent. West 
observed it in 23 out of 43 cases following delivery or abortion, and 
McClintock in 37 out of 70. Schroeder says that he has only once seen 
suppuration in 92 cases of distinctly demonstrable exudation — a result 
which is certainly totally opposed to common experience. Barker also 
states tliat in his experience suppuration in either pelvic peritonitis or 
cellulitis '^is very rare, except when they are associated with pyaemia 
or puerperal fever." It is certain that suppuration is more likely to 
occur in pelvic cellulitis than in pelvic peritonitis, but it unquestion- 
ably occurs, in Great Britain at least, much more frequently than the 
statements of either of these authors would lead us to suppose. 

Channels throug-h which Pus may Escape. — The pus may find 
an exit through various channels. In pelvic cellulitis, more especially 
when the areolar tissue of the iliac fossa is implicated, the most com- 
mon site of exit is through the abdominal wall. It may, however, open 
at other positions, and the pus may find its way through the cellular 
tissue and point at the side of the anus or in the vagina, or it may take 
even a more tortuous course and reach the inner surface of the thigh. 
Pelvic abscesses not uncommonly open into the rectum or bladder, caus- 
ing very considerable distress from tenesmus or dysuria. According to 
Hervieux, it is chiefly the peritoneal varieties which open in this way. 
Not unfrequently more than one opening is formed ; and when the pus 
has burrowed for any distance long fistulous tracts result which secrete 
pus for a length of time and are very slow to heal. Rupture of an 
abscess into the peritoneal cavity, especially of a peritonitic abscess, is 
a possible (but fortunately a very rare) termination, and will generally 
prove fatal by producing general peritonitis. In one case which I have 
recorded in the fifteenth volume of the Obstetrical Transactions suppu- 
ration was followed by extensive necrosis of the pelvic bones. Two 
similar cases are related by Trousseau in his Clinical Jlcdicine, but I 
have not been able to meet with any other examples of this rare com- 
plication, which was probably rather the result of some obscure sopti- 
c?emic condition than of extension of the inflammation. 

Prognosis. — The prognosis is favorable as regards ultimate recoverv, 
but there is great risk of a protracted illness which may seriously impair 
the health of the patient, especially if suppuration result. Hence it is 
necessary to be guarded in an expression of opinion as to the conse- 
quences of the disease. Secondary mischief is also far from unlikelv 
to follow from the physical changes produced by the exudation, such as 
permanent adhesions or malpositions of tlie uterus or organic aherations 
in the ovaries or Fallopian tubes. 

Treatment. — In the treatment of both forms of disease the import- 
ant points to bear in min^l are the relief of pain and the necessity of 
absolute rest; and to these objects all our measures must be subordiliate, 
since it is quite hopeless to attempt to cut short the inflannnation by any 
active medication. 

42 



658 THE PUERPERAL STATE. 

If the disease be recognized at a very early stage, the local abstrac- 
tion of blood by the application of a few leeches to the groin or to the 
hemorrhoidal veins may give relief, but the influence of this remedy 
has been greatly exaggerated, and when the disease is of any standing 
it is quite useless. Leeches to the uterus, often recommended, are, I 
believe, likely to do more harm than good (unless in very skilful 
hands) from the irritation produced by passing the speculum. Opiates 
in large doses may be said i6 be our sheet-anchor in treatment when- 
ever the pain is at all severe, either by the mouth, in the form of mor- 
phia suppositories, or injected subcutaneously. In the not uncommon 
cases in which pain comes on severely in paroxysms tlie opiates should 
be administered in sufficient quantity to lull the pain ; and it is a good 
plan to give the nurse a supply of morphia suppositories (which often 
act better than any other form of administering the drug), witli direc- 
tions to use them immediately the pain threatens to come on. When 
there is much pyrexia large doses of quinine may be given with great 
advantage along with the opiates. The state of the bowels requires 
careful attention. The opiates are apt to produce constipation, and the 
passage of hardened feces causes much suifering. Hence it is desirable 
to keep the bowels freely open. Nothing answers this purpose so well 
as small doses of castor oil, such as half a teaspoonful given every 
morning. Warmth and moisture, constantly applied to the lower part 
of the abdomen, give great relief — either in the form of large poultices 
of linseed-meal, or, if these prove too heavy, of spongio-piline soaked 
in boiling water. The poultices may be advantageously sprinkled with 
laudanum or belladonna liniment. I say nothing of the use of mercu- 
rials, iodide of potassium, and other so-called absorbent remedies, since 
I believe them to be quite valueless and apt to divert attention from 
more useful plans of treatment. 

The most absolute rest in the recumbent position is essential, and it 
should be persevered in for some time after the intensity of the symp- 
toms is lessened. The beneficial effect of rest in alleviating pain is 
often seen in neglected cases, the nature of which has been overlooked, 
instant relief following the laying up of the patient. 

When the acute symptoms have lessened, absorption of the exuda- 
tion may be favored and considerable relief obtained from counter-irri- 
tation, which should be gentle and long continued. The daily use of 
tincture of iodine until the skin peels perhaps best meets this indica- 
tion, but frequently repeated blisters are often very serviceable. This 
I believe to be a better plan than keeping up an open sore with savine 
ointment or similar irritating applications. 

When suppuration is established the question of opening the abscess 
arises. When this points in the groin and the matter is superficial, a 
free incision may be made ; and here, as in mammary abscess, the anti- 
septic treatment is likely to prove very serviceable. The abscess should, 
however, not be opened too soon, and it is better to wait until the pus 
is near the surface. The importance of not being in too great a hurry 
to open pelvic abscesses has been insisted on by West, Duncan, and 
other writers, and I have no doubt the rule is a good one. It is more 
especially applicable when the abscess is pointing in the vagina or rec- 



PELVIC CELLULITIS AND PELVIC PERITONITIS. 659 

turn, where exploratory incisions are apt to be dangerous, and when the 
presence of pus should be positively ascertained before operating. We 
have in the aspirator a most useful instrument in the treatment of such 
cases, which enables us to remove the greater part of the pus without 
any risk, and the use of which is not attended with danger even if 
employed prematurely. If it do not sufficiently evacuate the abscess, 
a free opening can afterward be safely made and a suitable drainage- 
tube inserted into the abscess-cavity. The surgical treatment of pelvic 
abscess is, however, too wide a subject to admit of being satisfactorily 
treated here. 

The diet should be abundant, but simple and nutritious. In the 
early stages of the disease milk, beef-tea, eggs, and the like will be 
sufficient. After suppuration a large quantity of animal food is neces- 
sary and a sufficient amount of stimulants. The drain on the system 
is then often very great, and the amount of nourishment jDatients will 
require and assimilate when a copious purulent discharge is going on is 
often quite remarkable. A general tonic plan of medication is also 
indicated, and such drugs as iron, quinine, and cod-liver oil will prove 
useful. 



i:ndex: 



ABDOMEN, adipose, enlargement of, 
161 

[color-line in pregnant women, 528] 

enlargement of, as a sign of pregnancy, 
151 

state of, after delivery, 556 
Abdominal pregnancy. See Extra-uterine 

Pregnancy. 
Abortion, 246 

causes of, 248 

difficulty in procuring artificial, 252 

liability to recurrence of, 248 

[opium treatment in threatened, 254] 

production of, in vomiting of pregnancy, 
203 

retention of secundines in, 253, 257 

symptoms of, 252 

treatment of, 253 

value of opium in prevention of, 253 

[Viburnum prunifolium in threatened, 
254] 
Abscess of mammae. See Mammary Ab- 
scess. 

pelvic. See Pelvic Cellulitis. 
After-coming head, application of forceps 

to, 313 
After-pains, 557 

treatment of, 559 
Age, influence of, in labor, 345 
Albuminuria in pregnancy, 146, 208 
relation of, to eclampsia, 581 
to puerperal insanity, 591 
Allantois, 108 
Amnii, liquor, 110 
Amnio-chorionic fluid, 112 
Amnion, formation of, 110 

pathology of, 239 

structure of, 110 
Amputations (iiitra-uterine), 244 
Auiomia in pregnancy, 207 

[pernicious, in parturient women, 207] 
Anaesthesia in labor, 299 

in forceps operations, 485 

value of, in difiicult cases of turning, 476 
Anasarca in prognanoy, 210 
Anteversiou of the gravid uterus, 219 
Antiseptic midwifery, 611 
Apopk^xy during or after labor, 643 
Arbor vil;v, 59 » 

Area germinativa, 106 
AroapoUucida, 106 
Arecilii, SO 

changes of, (hiring proguancy, 150 



Arm, presentation of (see Shoulder Presen- 
tation) ; dorsal displacement of, 336 

Arterial transfusion, 547 

Artificial human milk, 575 

respiration in cases of apparent still- 
birth, 563 

Ascites as a cause of dystocia, 380 

Asphyxia (idiopathic), 643 
of newborn children, 562 

Atropine, hypodermic injection of, in ri- 
gidity of. cervix, 359 

Auscultatory signs of pregnancy, 156 

BAGS (Barnes'). See Dilators. 
Ballottement, 155 
Bandl's ring, 139, 440 
Basilyst, the, 515 
Bilobed uterus, gestation in, 193 
Binder, uses of, 298 

Bladder, distension of, as a cause of pro- 
tracted labor, 345 
exfoliation of lining membrane of, 215 
state of, after delivery, 558 
Blastodermic membrane, 100 
division and layers of, 106 
Blastosphere, 99 
Blood, alteration in, after delivery, 552 

changes of, during pregnancy, 143 
Blood-diseases transmitted to Ibetus, 241 
Blunt-hook in breech presentation, 314 
Bowels, action of, after delivery, 561 
Breech presentations. See Pelvic Presen- 
tations. 
Broad ligaments of uterus, 69 
Bronchitis as a cause of protracted hd)or, 

346 
Brow presentations, 323 

C.ESAREAN section, 335, 364, 404. ol9 
causes of mortality after, 524 
causes requiring the operation. 521 
description ot", 528 
lii story o\\ 518 
post-nun-tem operation, 523 
results to child in, 521 
statistics of, 521 
substitutes lor, 533 
sutures in, 530 
[(Vsarean operation, before labor, 526] 
[causes of death tVom, 525] 
[dangers of, overestimated. 406] 
I ii\ America, 521 ] 
[in cancer of the cervix. 361] 



662 



IXDEX. 



[Csesarean operation in imj)action of foe- 
tus, 335] 
[records of tumor cases, 364] 
[under relative indications, 522] 
Calculus of bladder obstructing labor, 366 
Caput succedaneum, 283 
Carcinoma in pregnancy, 225 

obstructing labor, 360 
Cardiac murmurs in pulmonary obstruc- 
tion, 637 
Caries of teeth in pregnancy, 205 
Carunculae myrtiformes, 53 
Catheter, introduction of, 51 
Caul, 268 

Cellulitis, pelvic. See Pelvic Cellulitis. 
Cephalotribe, 507 
Cephaloti-ipsy. See Cranioiomy. 
Cervix uteri, 59 

alterations of, after childbirth, 59 
cavity of, 59 

dilatation of, in labor, 263 
hypertrophic elongation of, 360 
impaction of, before foetal head, 290 
incision of, for rigidity, 361 
lacerations of, 445 
modification of, by pregnancy, 139 
mucous membrane of, 63 
obstetrical, 440 

organic causes of rigidity of, 360 
rigidity of, as a cause of protracted la- 
bor, "358 
treatment of rigiditv, 359 
villi of, 63 
Charlotte, princess of Wales, death of, 354 
Child, the newborn. See Infant. 

risks to, in forceps operations, 492 
Childbirth, mortality of, 551 
Chloral, in labor, 299 

in rigidity of cervix, 359 
Chloroform in labor, 301 

in difficult cases of turning, 469 
in rigidity of cervix, 359 
Chorea in pregnancv, 214 
Chorion, 112 
primitive, 113 

vesicular degeneration of, 232 
Circulation of foetus, 132 
Cleavage of yelk, 99 
Clitoris. 51 
Cocaine in labor, 547 
Coccyx, 35 

ligaments of, 37 
mobility of, 36 
ossification of, 36 
Cold in the treatment of puerperal hyper- 
pyrexia, 627 
Colostrum, 564 
Complex presentations, 335 
Concealed internal hemorrhage, 420 
Conception, signs of, 147 
Constipation in pregnancy, 204 
Constriction of uterus, tetanoid, 362 
Continued fever in pregnancy, 223 
Convulsions (puerperal). See Eclampsia. 
Corps reticule, 110 



Corpus luteum, 84 

false, 84 
Cranioclast, 506 
Craniotomy, 504 

cases requiring, 509 

comparative merits of, and cephalotrip- 
sy, 512 

description of cephalotripsy, 513 

extraction of head by craniotomy-for- 
ceps, 515 

method of perforating, 511 

perforation of after-coming head, 512 

perforators, 506 

religious objections to, 504 
Craniotomy-forceps, 506 
Crotchets. o06 

Cyclical theory of menstruation, 92 
Cystocele. obstructing labor, 366 
[Cvsts. dermoid, prolapsed, obstructing 
pelvis, 366] 

DEATH, apparent, of newborn child. 
See Infant. 
from air in the veins, 644 
functional causes of, 643 
organic causes of, 643 
sudden, during labor and the puerjjeral 
state. 643 
Decapitation of foetus, 517 
Decidua, 101 

at end of pregnancv and after deliverv. 

■ 105 
cavitv between decidua vera and reflexa. 

i04 
divisions of, 101 
fatty degeneration of, as the cause of 

' labor, 260 
formation of decidua reflexa, 103 
structure of, 102 
[Deformities, spinal and pelvic, associated, 

387] 
Delivery, state of patient after, 552 
contraction of uterus after, 554 
[Macdufi-'s, 519] 

management of patient after, 558 
nervous shock after, 552 
prediction of date of, 165 
signs of recent, 168 
state of pulse after, 552 
[very rapid, case of, 357] 
weight of uterus after, 555 
Diabetes, 146 
Diameters of foetal skull. 125 

of pelvis, 41 
Diarrhoea in pregnancy, 203 
Diet of lying-in Avomen, 559 
Difierential diagnosis of pregnancy, 161 
Dilators (caoutchouc) in the induction of 
premature labor, 460 
in rigidity of cervix, 360 
Diphtheria in the puerperal state, 606 
Diseases of pregnancy, 199 
albuminuria, 208 
auferaia and chlorosis, 207 
carcinoma, 225 



INDEX. 



663 



Diseases of pregnancy, cardiac diseases, 224 

chorea, 214 

constipation, 204 

diarrhoea, 203 

disorders of the nervous system, 212 
respiratory organs, 205 
teeth, 205 
urinary system, 215 

displacements of gravid uterus, 218 

epilepsy, 225 

eruptive fevers, 222 

fibroid tumors, 227 

hemorrhoids, 204 

icterus, 225 

leucorrhoea, 216 

ovarian tumor, 226 

palpitation, 206 

paralysis, 213 

pneumonia, 223 

pruritus, 216 

ptyalism, 205 

syncope, 206 

syphilis, 224 

varicose veins, 217 

vomiting (excessive), 199 
Dropsies affecting the foetus, 243 
Ductus arteriosus, 133 

venosus, 133 
Dystocia from foetus, 370 

ECLAMPSIA, 578 
cause of death in, 581 

condition of patient between the attacks, 
580 

confusion from defective nomenclature, 
578 

exciting causes of, 583 

obstetric management in, 586 

pathology of, 581 

premonitory symptoms of, 579 

relation of, to labor, 580 

results to mother and child in, 581 

symptoms of, 579 

transfusion in, 549 

Tralibe and Rosenstein's theory of, 582 

treatment of, 583 

uroemic theory of, 581 

venesection in, 584 
, views of MacDonald, 583 
Ecraseur, use of, as a substitute for crani- 
otomy, 508 
Embolism. See Thrombosis. 
Embryotomy, 516 
Emotion, mental, as a cause of protracted 

labor, 346 
Epi blast, 106 

Epilepsy in pregnancy, 225 
Epileptic convulsions, 578 
Ergot of rye, 348 

as a means of inducing labor, 459 

mode of administration, 348 

objections to use of, 348 » 

value of, after delivery, 298 
Ergotino, hypodermic injection o{\ in post- ' 

partum hemorrhage, 42S 
Eruptive fevers in pregnancy, 222 | 



Erysipelas as a cause of puerperal septicwi- 

mia, 605 
Ether in labor, 301 

[safer to inhale than chloroform, 302, 
303] 
Evisceration, 518 

Exhaustion, importance of distinguishing 
between temporary and permanent, 
in labor, 348 
[Exostosis, pelvic, an obstruction to deliv- 
ery, 395] _ 
Expression, uterine (see Pressure) ; of the 

placenta, 296 
Extra-uterine pregnancy, 176 
abdominal variety of, 185 
causes of, 177 

changes of the foetus in, 186 
classification of, 176 
diagnosis of abdominal variety, 188 

of tubal variety, 181 
gastrotomy in, 185, 190 
pseudo-labor in, 187 
symptoms of rupture in, 181 
treatment after rupture, 185 
of abdominal variety, 189 
tubal variety, 179 

treatment of tubal variety, 183 
vaginal section in, 183 
Eye, diseases of, in pregnancy, 225 

FACE presentation, 315 
causes of, 315 
diagnosis of, 316 
difficulties connected Avith, 322 
erroneous views formerlv entertained of, 

315 
mechanism of delivery in, 317 
mento-posterior positions in^ 320 
prognosis in, 321 
treatment of, 322 
Fallopian tubes, 71 
False corpus luteum, 84 
False pains, character and treatment of, 

;287 
Faradization in apparent stillbirth, 563 
in destroying the vitality of the fivtus in 

abnormal pregnancies, 183 
in hemorrhage after delivery, 432 
in labor, 350 
[Fatigue, recurrent uterine, 346] 
Fibroid tumor in pregnancy, 227 

obstructing labor, 363 
Fillet, 503 

in breech presentations. 314 
nature of the instrument, 503 
objections to its use, 503 
Flattoueil pelvis, 305 
luvtal head, anatomy ot'. 123 

induction o( premature labor tor large 
size of, 457 
heart, sounds of, in pregnancy. 1 5i> 
Inx'tus, anatomy and physiology ot". 121 
appearance of a putrid, 246 

of. at various stages of development, 

121 
ai lenn, 122 



664 



INDEX. 



Foetus, circulation of, 132 

changes in circulation of, as cause of la- 
bor, 254 
in position of, during pregnancy, 
126 
death of, 245 

detection of position in utero by palpa- 
tion, 127 
early viability of, 247 
excessive development of, as a cause of 

difficult labor, 381 
explanation of its position in utero, 128 
functions of, 130 
nutrition of, 130 
pathology of, 241 
position of, in utero, 126 
respiration of, 131 
signs and diagnosis of death of, 246 
[Foetuses, very small, habitually produced 

by some mothers, 123] 
Fontanelles, 124 
Foot, diagnosis of, 306 
Foot presentations. See Pelvic Presenta- 
tions. 
Foramen ovale, 132 
Forceps, 478 
action of, 482 

advantage of pelvic curve in, 479 
application of, to after-coming head in 
breech presentations, 312 
within the cervix, 361 
[breech, 314] 
cases in which a straight instrument 

should be used, 480 
dangers of, 353, 491 

to child, 492 
description of, 478 

the operation, 485 
difference between high and low opera- 
tions, 484 
disadvantages of a weak instrument, 481 
[frequent use of, 355, 356] 

in modern practice, 352, 478 
high operations, 490 
[in America, 492-501] 
long, 480 

[Meigs' craniotomy, 516] 
preliminary considerations before using, 

485 
short, 478 
use of anaesthetics in forceps delivery, 

485 
use of, in deformed pelvis, 401 

in difficult occipito-posterior positions, 

326 
in protracted labor, 352 
Forceps-saw, 508 
Fossa navicularis, 53 
Funis. See Umbilical Cord. 

[corkscrew-formed, 238] 
Funnel-shaped pelvis, 385 

GALACTAGOGUES, 569 
Gal actor rhoea, 570 
Galvanism as a .means of inducing labor, 
459 



Gangrene of limbs from arterial obstruc- 
tion, 642 
Gastrotomy, after rupture of uterus, 444 

in extra-uterine pregnancy, 185, 190 
Gastro-elytrotomy. See Laparo-elytrotomy. 
Generative organs in the female, 49 

division according to function, 49 
Germinal vesicle, disappearance of, after 

impregnation, 99 
Gestation. See Pregnancy. 
Glycosuria in pregnancy, 146 

in lactation, 554 
Graafian follicle, 75 
structure of, 77 

HEMATOCELE, obstructing labor, 367 
Hand-feeding of infants, 574 

artificial human milk in, 575 

ass's milk in, 575 

causes of mortality in, 574 

cow's milk in, and its preparation, 575 

goat's milk in, 575 

method of, 577 
Head presentations, 272 

description of cranial positions in, 272 

division of, 273 

explanation of, 274 

frequency of first position, 274 

mechanism of first position, 274 

second position, 280 

third position, 280 

fourth position, 283 

relative frequency of various positions, 
273 
Heart, diseases of, in pregnancy, 224 
hypertrophy of, in pregnancy, 144 
Hemorrhage, accidental, 418 

causes and pathology of, 419 

concealed internal, 420 

diagnosis, prognosis, and treatment of 
concealed internal, 420 

prognosis of, 420 

symptoms and diagnosis of, 419 

treatment of, 421 
after delivery, 421 

causes of, 422 

constitutional predisposition to, 426 

curative treatment of, 428 

from laceration of maternal structures, 
434 

nature's mode of preventing, 270, 422 

preventive treatment of, 427 

secondary causes of, 424 
treatment of, 434 

symptoms of, 426 

transfusion of blood in, 434 

vinegar as a styptic in, 434 

(secondary), 434 
distinction between, and profuse lochial 
discharge, 435 

local causes of, 436 

treatment of, 437 

unavoidable. See Placenta Prcevia. 
Hemorrhoids, in pregnancy, 204 
Hernia, in labor, 367 
Hour-glass contraction of uterus, 424 



INDEX. 



665 



Hour-glass contraction, ante-partura, 362 
Hydatids of uterus, 231 
Hydraranios, 239 [240] 
Hydrocephalus of foetus as a cause of dif- 
ficult labor, 378 
Hydrorrhoea gravidarum, 230 
Hvmen, 52 
Hypoblast, 106 
Hysteria during labor, 578 

TCTERUS, 225 

J. [Impaction of bowels from eating clay 

an obstacle to delivery, 367] 
Induction of premature labor. See Pre- 
mature Labor. 
Inertia of the uterus, frequent child-bear- 
ing as a cause of, 345 
Infant, apparent death of, 562 

appearance of, in cases of apparent 

death, 562 
clothing of, 564 
evils of over-suckling, 565 
management of, 566 

when food disagrees, 577 
treatment of apparent death of, 562 
various kinds of food of, 577 
washing and dressing of, 564 
Infantile mortality, diminution of, as a 
reason for more frequent use of for- 
ceps, 352 
Inflammatory diseases affecting the foetus, 

242 
[Injections, uterine, of hot water, 431] 
Insanity (puerperal), 594 
classification of, 587 
of lactation, 593 
of pregnancy, 588 
predisposing causes of, 589 
puerperal (proper), 590 
causes of, 591 
form of, prognosis of, 589 
post-mortem signs of, 593 
question of removal to an asylum, 597 
symptoms of, 593 

transient mania during delivery, 590 
treatment of, 595 

during convalescence, 597 
Insomnia in pregnancy, 212 
Intermittent fever affecting the foetus, 241 
Intestines, disorders of, as influencing labor, 

345 
Inversion of uterus. See Uterus. 
Involution of uterus, 554 
Irregular uterine contractions after labor, 
424 
as a cause of lingering labor, 347 
Irritable bladder in pregnancy, 215 
Ischium, planes of the, 46 



"AUNDICK 



in pregnancy, 22o 



KIESTKIN, 146 
Knee piesoutatio'.i. 306 
Knots on the umbilical I'oni, 238 
Ky[)hotic deformity of pelvis, 393 



LABIA raajora, 49 
Labia minora, 50 
Labor, 259 

age, influence of, on, 345 
anaesthesia in, 299 
arrest of, 168 
causes of, 259 

[of missed, 196-199] 

of precipitate, 356 

of protracted, 343 
character and source of pain in, 265 

of false pains, 267 
cocaine in, 347 
dilatation of cervix in, 263 
duration of, 271 

effect of uterine contractions in, 261 
evil effects of protracted, 342 
induction of. See Premature Labor. 
influence of stage of, in protracted, 343 
management of, in deformed pelvis, 400 

of natural, 284 

of third stage of, 294 
mechanism of, in head presentation, 272 
obstructed by faulty condition of the soft 

parts, 358 
period of day at which labor commences, 

271 
phenomena of, 259 
position of patient during, 288, 290 
precipitate, 352 
preparatory treatment, 284 
prolonged and precipitate, 342 
rupture of membranes in, 263 
stages of, 263 

symptoms of protracted, 344 
treatment of protracted, 347 
Lactation, defective secretion of milk in, 
569 
diet of nursing women during, 567 
diseases of the eye during, 571 
evil results of prolonged, 565 
excessive flow of milk in, 570 
importance of, to mother, 565 

of wet-nursing to child, 565 
insanity of, 593 
management of, 567 
means of arresting secretion of milk in, 

period of weaning in, 568 
Lamina^ dorsales, 106 
Laparo-elytrotomy, 534 

[inadmissible in many Ca^sarean cases. 

535] 
[performed on either side, 537] 
[statistics of. 535] 
Lead-poisoning, atlbcting the tlvtus, 241 

as a cause of abort icni. 251 
LeucorrluiMi. in pregnancy, 216 
Lever. See Vcctia. 
Liquor amnii, 110 
deliciency of, 241 
source oi\ 112 
spurious, 1 12 
uses of. 112 
LithopaHliou. ISS 
Liver, acute yellow atrophy ot'. 225 



666 



IXDEX. 



Liver, changes of, in pregnancy, 145 
Lochia, 556 

occasional fetor of, 557 

variation in amount and duration of, 557 
Lving-in hospitals, mortality in, 589 
Lypothemia, 150, 206 

MALAEIAL puerperal fever, 622 
Malpresentations, peculiar form of 
bag of membranes in, 305 
Mammary abscess, 571 

antiseptic treatment of, 572 
signs and symptoms of, 571 
treatment of, 572 
changes during pregnancy, 150 

their diagnostic value, 151 
glands, 79 

their sympathetic relations with the 
uterus, 81 
Mania, puerperal. See Insanity, Puerperal. 
Mastitis, 571 
Measles, affecting the foetus, 241 

in pregnancy, 223 
Meconium, 135 

Membranes, artificial rupture of, 289 
puncture of, as a means of inducing 
labor, 458 
Menstruation, 81 
cessation of, 93 

changes in Graafian follicle after, 82 
during pregnancy, 148 
[from unimpregnated side of a double 

uterus, 146] 
period of, duration, and recurrence, 87 
purpose of, 92 

quantity of blood lost in, 88 
sources of blood in, 89 
theory of, 90' 
vicarious, 93 
Mesoblast, 106 
Milk, artificial human, 575 
ass's, 575 

cow's, and its preparation, 575 
defective secretion of, 569 
[diet for nursiug mothers, 569] 
excessive secretion of, 570 
goat's, 575 

means of arresting the secretion of, 568 
secretion of, after delivery, 565 
transfusion of, 544 
Milk fever, 553 
Miscarriage. See Abortion. 
Missed labor, 194 
Moles, 250 

Monstrosity (double), 374 
classification of, 374 
mechanism of delivery in, 375 
Mons Veneris, 49 
^lontgomery's cups, 103 
Morning sickness. 149 
Mortality of childbirth. 551 

[of infants delivered by induction of 
premature labor, 463] 
Mucous membi'ane of uterus. See Uterus. 
MuUer's operation, 532 
Mvxoma tibrosum, 234 



NERVOUS shock after delivery, 552 
Nervous system, changes in, during- 
pregnancy, 145 
disorders of, in pregnancy, 212 
excitability of, in puerperal women, 583 
Neuralgia in preanancv. 213 
Nipple, 80 
Nipples, depressed, 569 

fissures and excoriations of, 570 
Nursing. See Lactation. 
Nutrition of fcetus, 130 
Nymphffi. See Labia Minora. 

OBLIQLELY-contracted pelvis, 392 
Obstetric bag, 285 
Obstetrical cervix, 440 
Occipito-posterior positions, difficult cases 
of, 324 
causes of face-to-pubes deliverv in, 

325 
forceps in, 326 
treatment of, 325 
vectis or fillet in, 325 
Omphalo-rnesenteric artery and vein, 108 
Opiates, use of, after delivery, 558 
I Os innominatum, 33 

! Osteomalacia, as a cause of deformity, 383 
1 [not an American disease, 392] 
Osteophytes, formation of, during preg- 
nancy, 145 
Os uteri, constriction of internal, as a 

cause of dystocia, 362 
I dilatation of, as a means of inducing 

I labor, 460 

occlusion of, in labor, 360 
Ovarian pregnancy. See Extra-uterine 
Pregnancy. 
tumor in pregnancy, 226 
Ovariotomy in pregnancy, 226 
i Ovary, 73 

functions of, 81 
structure of, 74 
vascular arrangements of, 78 
Ovule, 78 

changes in, after impregnation, 98 
when retained in liter o after its death^ 
25p 
formation of, 75 
Ovum, blighted, retained in ittero, 250 
Oxytocic remedies, 348 

PAINS, after-. 557 
_ false, 286 
irregular and spasmodic, as a cause of 

protracted labor, 347 
labor-, 265 
Palpitation in pregnancy, 206 
Pampiniform plexus, 66 
Paralysis in pregnancy, 213 

from embolism of the cerebral arteries, 

642 
from embolism of the main arteries of 
i the limb, 642 

: Parovarium, 69 
Parturient canal, axis of, 44 
i Pathology of decidua and ovum, 229 



INDEX. 



667 



Pelvic cellulitis and peritonitis, 652 

connection with septicaemia, 653 

etiology of, 653 

importance of distinguishing the two 
forms of disease, 653 

opening of abscess in, 658 

prognosis of, 657 

relative frequency of the two forms 
of disease, 655 

results of physical examination, 655 

seat of inflammation in cellulitis, 654 
in peritonitis, 654 

suppuration, in, 656 

symptomatology, 655 

terminations of, 656 

treatment of, 657 

two distinct forms of disease, 652 
Pelvic presentations, 303 

application of forceps to the after- 
coming head in, 313 

causes of, 304 

danger to children in, 304 

diagnosis of, 305 

frequency of, 304 

management of impacted breech in, 
313 

mechanism of, 306 

prognosis in, 304 

treatment of, 310 
Pelvis, alterations in articulations of, dur- 
ing pregnancy, 39 
anatomy of, 33 
articulations of, 36 
axes of, 44 

Cesarean section in deformities of, 404 
causes of deformity of, 382 
comparative estimate of turning and 

forceps in deformity of, 404 
[coxalgic deformity of, 392] 
craniotomy in deformity of, 404 
diagnosis of deformity, 398 
deformities of, 382 
development of, 46 
difference according to race, 47 
differences in the two sexes, 40 
division into true and false, 34 
fi-qually contracted, 384 

enlarged, 384 
flattened, 385 

forceps in deformity of, 401 
funnel-shaped, 385 

induction of premature labor in deform- 
ity of, 404 
infavitile, 46 
kyphotic, 393 
ligaments of, 37 
masculine, 385 

mechanism of delivery in deformed, 396 
movements in the articulations of, 38 
obli(iuely contracted, 392 
planes of, 43 
Eobert's, 393 
scoliotic, 387 

[small, masked by external develop- 
ment of adipose tissue, 38 Ij 
soft parts connected with, 48 



Pelvis, tumors of, 394 

turning in deformity of, 402 
undeveloped, 384 
Pelvimeters, various forms of, 398 
Perchloride of iron, injections of, in post- 
partum hemorrhage, 433 
Perforation of after-coming head, 512 
Perforators, 505 

Perineum, distension of, in labor, 2G9, 291 
incision of, 292 
laceration of, 293 
relaxation of, 291 

rigidity of, as a cause of protracted la- 
bor, 363 
Peritonitis, pelvic. See Pelvic Cellulitis. 

puerperal. See Septicemia. 
Phlegmasia dolens. See Thrombosis, pe- 
ripheral venous. 
Placenta, adhesion of, after delivery, 425 
degeneration of, 119 
detachment of, in labor, 269 
diseases of, 235 
expression of, 296 
[expulsion of, 295] 
foetal portion of, 115 
form of, in man and animals, 114 
formation of, from chorion, 113 
functions of, 1 19 
maternal portion of, 116 
minute structure of, 115 
pathology of, 234 
sinus, system of, 117 
sounds produced during separation of, 

160 
treatment of adherent, 430 

of, in extra-uterine foetation, 191 
Placenta membranacea, 234 
Placenta previa, 407 
causes of, 407 

causes of hemorrhage in, 410 
natural termination of labor in. 411 
pathological changes of placenta in, 

411 
prognosis, in, 412 
sources of hemorrhage in, 409 
summary of rules of treatment in. 417 
symptoms of, 408 
treatment of, 413 
turning in, 416 
Placenta^ succenturia\ 235 
Placentation, metadiscoidal. 114 

discoidal, 114 
Placentitis. 236 
Plugging of vagina. 256 
Plural births. f70, 370 

arrangement of placenta^ and mem- 
branes in, 172 
causes ot". 171 
diagnosis ol", 173 
relative frequency ol", in dill'erent 

countries. 170 
sex of children in, 171 
treatment of, 370 
Pneumonia in pregnancy. 223 

puerperal embolic, 639 
"Polar globule," \)\^ 



668 



INDEX. 



[Polypus, an obstacle to labor, 369] 
Porro's operation, 531 

[followed by crural phlebitis, 650] 
[in Great Britain, 532] 
[statistics, 532] 
Position of cranium in head presentation. 

See Head Presentation. 
Post-partum hemorrhage. See Hemor- 
rhage. 
Pregnancy, 136 
abnormal, 170 

affections of respiratory organs, 205 
alteration of color of vaginal mucous 

membrane, as a sign of, 155 
ballot tement, as a sign of, 155 
changes in the blood during, 143 
changes in the liver, lymphatics, and 

spleen during, 144 
changes in the urine during, 145 
cocaine in, 201. Vide Labor. 
complicated Avith ovarian tumor, 226 

with fibroid tumor, 227 
[cough of, 206] 
deposits of pigmentary matter during, 

152 
diabetes in, 212 
differential diagnosis of, 161 
diseases of eye during, 225 
dress of patient in, 285 
duration of, 164 
[dyspnoea of, 206] 
[eneuresis of, 216] 
enlargement of abdomen as a sign of, 

152 
extra-uterine (see Extra-uterine Preg- 
nancy), [183, 184] 
[exsective operation Avhere the foetus 

is living and viable, 191, 192] 
foetal movements in, 153. 
[toxic injection of cvst, dangerous, 
184] 
formation of osteophytes during, 145 
hypertrophy of the heart during, 144 
in cases of double uterus, 67 
in the absence of menstruation, 148 
intermittent uterine contractions, as a 

sign of, 153 
liver, changes of, in, 145 
prolapse of the uterus in, 218 
protraction, 166 
pruritus in, 216 
ptyalism in, 205 
quickening, 153 
sickness of, 149 
signs and diagnosis of, 147 
sounds produced by the foetal move- 
ments in, 160 
spurious, 163 

sympathetic disturbances of, 149 
tetanus in, 215 
uterine fluctuation in, 155 
vaginal signs of, 154 
pulsation in, 155 
Premature labor, 247 

historv of the operation of induction 
of, 456 



Premature labor, induction of, 456 
in deformed pelvis, 404 
injection of carbonic acid gas as a 

means of inducing, 462 
insertion of flexible bougie as a 

means of inducing, 462 
objects of the operation of induction 

of, 456 
oxytocics as a means of inducing, 459 
period for the induction of, in de- 
formed pelvis, 406 
precautions as regards the child in 

the induction of, 463 
puncture of the membranes as a 

means of inducing, 458 
separation of the membranes as a 

means of inducing, 461 
vaginal and uterine douches as a 
means of inducing, 461 
Pressure as a means of inducing uterine 
contractions, 350 
mode of applying, 351 
Prolapse of umbilical cord. See Umbil- 
ical Cord. 
Pronucleus, female, 99 

male, 99 
[Protector for Iving-in bed, Kellv's rub- 
ber, 286] ' 
Pseudo-labor, 187 
Ptyalism in pregnancy, 205 
Puerperal convulsion. See Eclampsia, 
fever. See Septiccemia. 
mania. See Insanity. 
pneumonia, 640 
state, 551 

after-treatment in, 561 
diet and regimen in, 558 
diminution of uterus in, 554 
importance of prolonged rest in, 561 
pulse in, 552 

secretions and excretions in, 553 
temperature in, 553 
[Pullulation, arrested, 245] 
Pulmonary arteries, anatomical arrange- 
ment of, as favoring thrombosis, 
632 



Q 



UICKENING, 153 
Quinine as an oxytocic, 349 



RACE, as influencing the size of the 
foetal skull, 126 
Pecto-vaginal fistula, 446 
Eespiration of foetus, 131 
Ketroversion of the gravid uterus, 219 
Rickets as a cause of pelvic deformity, 383 
Kingof Bandl, 139, 440 
Eosenmiiller, organ of. See Parovarium. 
Round ligaments of the uterus, 71 
Rules for monthly nurses, 560 
Rupture of uterus. See Uterus. 

SACRUM, anatomy of, 35 
mechanical relations of, 35 
! Salivation in pregnancy, 205 
i Scarlet fever affecting the foetus, 241 



INDEX. 



669 



Scarlet fever, in pregnancy, 223 
in the puerperal state, 605 
Scoliotic deformity of pelvis, 387 
Scybala? in the rectum obstructing labor, 

367 
Septicaemia (puerperal), 598 
bacteria in, 612 
channels of diffusion in, 613 

through which septic matter may be 
absorbed, 602 
cold in treatment of, 627 
conduct of practitioner in regard to, 

611 
contagion from other puerperal patients 

as a cause of, 609 
description oi', 618 
division in auto-genetic and hetero-gen- 

etic forms, 603 
epidemics of, 600 
history of, 599 
importance of antiseptic precautions in, 

611 
influence of cadaveric poison as a cause 
of, 604 
of zymotic disease in causing, 605 
its connection with pelvic cellulitis and 

peritonitis, 653 
local changes in, 613 
malarial, 622 

mode in which the poison may be con- 
veyed to patients in, 610 
mortality in lying-in hospitals, 599 
nature of septic poison, 612 
pathological phenomena in, 614 
prevention of, 612 
pygemic forms of, 621 
sewer gas as a source of infection, 607 
sources of auto-infection in, 603 

of hetero-infection, 604 
symptoms of the intense forms, 618 
theory of an essential zvmotic fever, 
601 
of identitv with surgical septicsemia, 

601 
of local origin, 600 
treatment of, 622 
venesection in, 626 

Warburg's tincture in the treatment of, 
627 
Sex, discovery of, of foetus during preg- 
nancy, 157 
of foetus as influencing the size of the 
skull, 126 
Shoulder presentations, 328 
diagnosis of, 331 
division of, 328 
mechanism of, 332 
prognosis and frequency of, 330 
s[H)ntanoous version in,' 333 

evolution in, 333 
treatment oi', 335 
Siamese twins, how born, 375 ' 
Sickness of pregnancy, 149 
Smallpox aflecting tlie foetus, 241 

in pregnancy, 222 
Smith's, Tyler, theory of labor, 261 



Spondyl-olisthesis, 388 [389] 
Spondylolizema, 390 
Spontaneous evolution, 333 

version, 333 
Spurious liquor amnii, 112 

pregnancy, 163 
diagnosis of, 164 
symptoms of, 163 
[Statistics of old Cesarean operations of 

little practical value now, 520] 
Stillbirth, apparent, 562 

treatment of, 562 
Subzonal membrane, 107 
Sugar, in urine of pregnancy, 146 
Superfecundation and superfoetation, 173 
[Sutures in Csesarean operations, 530] 

of foetal liead, 124 
Symphysiotomy, 533 

[in Naples, 533] 
Syncope during or after labor, 643 

in pregnancy, 206 

[relieved by elevating the body and 
lowering the head, 432] 
Syphilis affecting the foetus, 242 

as a cause of abortion, 251 

in pregnancy 224 

TEMPERATURE after delivery, 553 
Tetanus in pregnancy, 215 
Thrombosis (peripheral venous), 645 
changes in thrombi in, 649 
condition of the affected limb, 646 
detachment of emboli in, 649 
history and pathology of, 647 
progreir^s of the disease, 647 
symptoms of, 645 
treatment of, 650 
(puerperal), 629 
arterial thrombosis and embolism, 641 
cardiac munnur in pulmonary, 637 
cases illustrating recovery from pulmo- 
nary, 635 
causes of death in pulmonary, 638 
clinical facts in favor of pulmonary, 633 
conditions which favor thrombosis in 

the puerperal state, 631 
distinction between thrombosis and em- 
bolism, 631 
phlegmasia dolens a consequence of, 629 
post-mortem appearance of clots in pul- 
monary, 638 
pulmonary, as a cause of pleuro-pnou- 

monia, 640 
question of primary thrombosis in the 
pulmonary arteries. 632 
of recovery from pulmonary, 634 
symptoms of arterial. 641 

of pulmonary obstruction in. 634 
treatment of arterial, 642 
of pulmonary, ()39 
of uterine vessels. 422 
Thrombus. See Uamatocele. 
Toothache in pregnancy, 205 
Transfusion of blood. 539 

addition oi cheinical reagents to prevent 
coaii'ulation oi tibrin. 542 



670 



INDEX. 



Transfusion of blood, cases suitable for the 
operation, 544 
dangers of the operation, 544 
defibrination of blood in, 548 
difficulties of the operation, 541 
effects of successful transfusion, 550 
history of the operation, 539 
immediate transfusion, 541 
method of injecting defibrinated blood, 
549 
of performing immediate transfusion, 

546 
of preparing defibrinated blood, 548 
nature and object of the operation, 540 
Schtifer's directions for immediate, 546 
secondary effects of, 549 
statistical results of, 544 
[with defibrinated blood, 550] 
Tropics, influence of residence in, on labor, 

345 
Trunk, presentation of. See Shoulder Pres- 
entations. 
Tumors, diagnosis of uterine and ovarian, 
162 
foetal, 243 

obstructing labor, 380 
(maternal) obstructing delivery, 363 
Tunica albuginea, 75 
Turning, 464 

after perforation, 512 

anesthesia in, 469 

[Braxton Hicks' bimanual method in 

placenta prsevia, 418] 
by combined method, 470 
by external manipulation only, 466 
cases suitable for the operation, 466 

for operating by combined method, 465 
cephalic, 464 

choice of hand to be used, 469 
history of the operation, 464 
in abdomino-anterior positions, 475 
in deformed pelvis, 415 
in placenta prpevia, 415, 475 
method of cephalic, 467 

of performing by external manipu- 
lation, 466 
of podalic, 472 
object and nature of the operation, 465 
period when the operation should be 

performed, 469 
podalic, 469, 472 
position of patient in, 468 
statistics and dangers of, 465 
value of anaesthetics in difficult cases of, 
476 
Twins. See Plural Births. 
[Carolina, how born, 377] 
conjoined, 374 
locked, 371 

UMBILICAL cord, 119 
knots of, 120, 238 
ligature of, 294 
pathology of, 238 
prolapse of, 337 

diagnosis of prolapse of, 339 



Umbilical cord, prolapse of, causes of, 
339 
frequency of, 337 
postural treatment of, 340 
prognosis of, 338 
reposition of. 341 
treatment by laceration, 293 
Umbilical souffle, 159 

vesicle, 108 
Urachus, 109 

Ur?emia, in connection with eclampsia, 581 
in connection with puerperal insanitv, 
591 
Urethra, 52 

Urine, changes in, during pregnancy, 145 
retention of, after delivery, 558 
[to be examined at once in eclamptic 
cases, 587] 
[Uterine contractions during gestation, in- 
termittent, and sometimes painful, 
154] 
fluctuation, as a sign of pregnancy, 155 
[rupture, rational treatment of, 448, 449] 
souffle, 159 
Utero-sacral ligaments, 71 
Uterus, 56 

analogy of interior of, after delivery, 
and stump of an amputated limb, 
105 
anomalies of, 67 

ante-partum hour-glass contraction, 362 
arrangement of muscular fibres of, 61 
axis of, during pregnancy, 138 
changes in cervix during pregnancy, 139 
in form and dimensions of, during 

pregnancy, 136 
in mucous membranes of, after deliv- 
ery, 554 
in mucous membranes of, after im- 
pregnation, 100 
in tissues of, during pregnancy, 141 
in the vessels of, after delivery, 555 
congestive hypertrophy of, 162 
contractions of, in labor, 262 
dimensions of, 58 

diminution in size of, after delivery, 554 
distension of, as a cause of labor. 260 

by retained menses, 161 
fatty transformation of, after delivery, 

555 
gastrotomy in, 444 
hour-glass contraction, 424 
intermittent contractions of, during preg- 
nancy, 153 
internal surface of, 59 
inversion of, 449 
[inverted, spontaneous reposition of the, 

454, 455] 
involution of, 554 

differential diagnosis of, 451 

production of, 451 

results of phvsical examination in, 

450 
symptoms of, 450 
treatment of, 453 
ligaments of. 69 



INDEX. 



671 



Uterus, lymphatics of, 66 

malposition of, as a cause of protracted 

labor, 346 
mode of action in labor, 264 
mucous membrane of, 62 
muscular fibres of, 61 
nerves of, &Q 
[partitioned, 68] 
regional division of, 59 
relations of, 57 
retroversion of gravid, 220 
rupture of, 438 

alterations of tissues in, 439 

causes of, 439 

comparative result of various methods 
of treatment in, 444 

prognosis of, 443 

seat of laceration in, 438 

symptoms of, 441 

treatment of, 443 
size of, at various periods of pregnancy, 

137 
state of, in protracted labor, 344 
structures composing, 60 
utricular glands of, 62 
vessels of, 64 
weight of, after delivery, 555 

YAGINA, 53 
bands and cicatrices of, obstructing 
delivery, 360 
contraction of, after delivery, 556 
lacerations of, 445 
orifice of, 52 
structure of, 54 
Varicose veins in pregnancy, 217 



Vectis, 502 

action of, 502 

cases in which it is applicable, 502 
Veins, entrance of air into, as a cause of 

sudden death after delivery, 644 
Venesection for rigidity of cervix, 361 
Version. See Turninf/. 

[bimanual, in breech cases, 305] 

[by the vertex, 327] 
Vesico-uterine ligaments, 71 
Vesico- vaginal fistula, 446 
Vestibule, 51 

Vicarious menstruation, 93 
Vinegar as a styptic in post-partum hem- 

orrhage,"433 
Vomiting in pregnancy, 199 
Vulva, 49 

condition of, after delivery, 556 

oedema of, obstructing labor, 367 

vascular supply of, 53 
Vulvo-vaginal glands, 53 

WAEBURG'S tincture, 627 
Weaning. See Lactation. 
Wet-nurse, selection of, 566 

[diet of, 567] 
Wolffian bodies, 69, 121 
[Womanhood, precocious physical, 86] 
[Womb, circular contraction of the middle 

of the (Blundell), 362] 
Wounds of the foetus, 243 

ZONA pellucida, 78 
Zvmotic disease, affecting the foetus. 
' 241 
as a cause of septica?mia, 606 



THE END 



LEA BROTHERS S CO.'S 
I 

f CLASSIFIED CATALOGUE 

? OP 

rMDOLMD SURGICAL 

IPttblications. 



€0 

S 

"""% 

■jf In asking the attention of the profession to the works advertised in the following pages, 

O the publishers would state that no pains are spared to secure a continuance of the confi- 

^ dence earned for the publications of the house by their careful selection and accuracy and 

O finish of execution. 

"^ The large number of inquiries received from the profession for a finer dass of bindings than is 

■q_ usually placed on medical books has induced its to put certain of our standard publications in 

g half Mussia; and, that the growing taste may be encouraged, the prices have been fixed at so small 

O an advance over the cost of sheep as to place it within the means of oil to possess a library that 

*^ shall have attractions as well for the eye as for the mind of the reading practitioner. 

The printed prices are those at which books can generally be supplied by booksellers 

^ throughout the United States, who can readily procure for their customers any works not 

C^ kept in stock. Where access to bookstores is not convenient books will be sent by mail by 

fc" the publishers postpaid on receipt of the printed price, and as the limit of mailable weight 

O) has been removed, no difficulty will be experienced in obtaining through the post-office 

^ any work in this catalogue. No risks, however, are assumed either on the money or on 

JSL the books, and no publications but our own are supplied, so that gentlemen will in most 

^ cases find it more convenient to deal with the nearest bookseller. 
■O LEA BKOTHERS & CO. 

m^ Nos. 706 and 708 Sansom St., Philadelphia, September, 1889. 



Practical Medical Periodicals. 



o 

g THE AMERICAN JOURNAL OF THE MEDICAL ^ To one address, 

>* SCIENCES, Monthly, $4.00 per annum. I ^''^^'^sq 

C« THE MEDICAL NEWS, Weekly, $5.00 per annum. J per annum. 

^ THE MEDICAL NEWS VISITING LIST (3 styles, see p. 3), $1.25. 
E With either or both above periodicals, in advance, 75c. 

to THE YEAR-BOOK OF TREATMENT (see p. 17), $1.25. With 

^ either JOURNAL or NEWS, or both, 75c. Or JOURNAL, 

c: NEWS, VISITING LIST and YEAR-BOOK, $8.50, in advance. 

o 



OP 

E 



WITH 1889, The Journal enters upon its sixty-ninth and The 
News upon its forty-seventh year. Anticipating the require- 
ments of the times, The News changed from a monthly journal to a 
vastly larger weekly newspaper in 1882, and The Journal changed from 
a quarterly to a monthly in 1888, increasing its contents and simultaneously 
reducing its price. Jointly these two periodicals combine all that is possible 
and desirable in medical journalism, the promptness of the newspaper and 
the elaboration of the magazine. (Continued oi next page.) 



2 Lea Brothers & Oo.'s Periodicals — Am. Journal, Medical News. 

The Anierican Joniiiial and T|e Ijedical fleto^. 

Continued from First Page, 

Great care is exercised to make them thoroughly practical and of the 
utmost possible assistance in the everj-day work of the physician, surgeon 
and obstetrician. The Departments of Progress, for instance, during 
1888, contained 2300 individual articles on Medical Advances, gathered 
from the medical periodicals of the world. The Original Departments 
are filled with important communications from the most practical minds of 
the profession on both sides of the Atlantic, and the Reviews convey 
impartial judgments, as to the value of the most recent additions to the 
literature of medicine. In addition to the above features common to both, 
The News contains carefully gathered details of advanced Hospital Treat- 
ment, skilful Editorials on living topics, News Items, Society Proceedings, 
Notes and Queries, Correspondence, etc. 

Designed to fill distinct and complementary spheres, these periodicals 
are most advantageously read in conjunction, and to lead every practi- 
tioner to prove this for himself the commutation rate has been placed 
at the very low figure of $7.50. Their cheapness at this rate is rendered 
obvious by the consideration that they contain most valuable matter, 
equivalent to 9 octavo volumes of 700 pages' each. Although fitted to 
be read together, each periodical is individually complete and contains 
no duplicated matter, so that every reader of either is kept thoroughly 
posted. The reader of both gains the grasp of medical advance which is 
assured by locating matters from different points of view. 

As a premium for advance-payment to either or both the above 
periodicals, The Year-Book of Treatment (see page 17) is furnished for 
75 cents (regular price, §1.25). This convenient work gives an inde- 
pendent and classified statement of the value and uses of such remedies 
as have been introduced and tested with success during the year. 

Similarly, The Medical News Visiting List, the most perfect work of 
its kind (see page 3), is furnished to advance-ipiiymg subscribers for 75 
cents (regular price, §1.25). Thumb-letter index, 25 cents extra. 

OR, AS A SPECIAL OFFER, 

Journal, News, Year-Book and Vj siting List, in advance, $8.50. 

Subscribers can obtain^ at the close of each volume, cloth covers for 
The Journal [one annualhj)^ and for The News (one annually)^ free by 
mail, by remitting Ten Cents for The Journal cover, and Fifteen Cents 
for The News cover. 



The safest mode of remittance is by bank check or postal money 
order, drawn to the order of the undersigned ; where these are not acces- 
sible, remittances for subscriptions may be sent at the risk of the publishers 
by forwarding in registered letters. Address, 

LEA BROTHERS & CO,, 706 & 708 Sansom Street, Philadelphia. 



Lea Brothers & Co.'s Publications— Period., Manuals, 



THE MEDICAL WEWS VISITING LIST FOR 1890 

Has been revised and brought thoroughly up to date in every resoect Tf r-nn 
tains 48 pages of text, induding calendar for two years- obsIetnV.?W.;n. \ 
of dentition; tables of weights and measures and comparatiVe sS in^^^^^^^^^ trT^ 
amining the urine; list of disinfectants; table of eruptive feVeS lists o/^^^^^ 
and remedies not generally used ; incompatibles, poisons and antk/ofpf • If "fi^ remedies 
tion; table of doses, prepared to accord with the'terevislon of tl U 's P^^r^^ '"'^'•^' 
an extended table of Diseases and their remedies Ind^f.o^ T i-'?^'^P'^^^» 
teries. . 176 pages of blanks for all recordTofp'rSS and etableTabt TZ '' T 
bound in limp Morocco, with pocket, pencil, rubber and catheSr scale ^^^^^^^^^l^ 

A few notices of this Visiting List are appended : 



This list IS all that could be desired. It con- 
tains a vast amount of useful information, especi- 
ally for emergencies, and gives good table of doses 
and therapeutics.— Canadian Practitioner, Jan '88 

It IS a masterpiece. Some of the features are 
Sn?"hf 'fi^ ^?^^ ^^^^^^1 News Visiting List!" 
notably the Therapeutic Table, prepared by Dr t 
Lauder Brunton, which contains the list of dis- 



aTst o7^fhf l^^P^^^^!^^.^"^' gi^i°g "°der each 
trifir^lJ \K'''^'''^^^ ^^"^S^ employed in the 



ts:e medical news psysicians' ledger. 

Containing 400 pages of fine linen " ledger " naner ruled ^o th«f «li +1.. . r 

HARTSHOBNE, MEWBT^A^m^. D., LL. D., 

Lately Professor of Bygiene in the University of Pennsylvania. 

Second edition, thoroughly reyised and sreat v imnrriS t' *'"'Sei7 and Obstetrics, 
volume of 1028'pages,wV477m:L:SonrStn"2Yf-leitLrio.0l^^^ "^^' ''■"" 



4^Ti^^ ^^j^'i* ^^. '^^^ manual is to afford a conven- 
ient work of reference to students during the brief 
Ton m«dt' t^"^'. command while in aftendance 
upon medical lectures. It is a favorable sign that 
H^!:\ ^^^^ ^'''^^'^ necessary, in a short space of 
Thi Nih 'f "f- * ^^^ ^"^ carefully revised edition! 
iii^ Illustrations are very numerous and unusu- 
f/i^H?'^*"!: ^""^ /^^^ P*^* «««™» to have received 
l^T^ ^^^r ^^ attention. We can conceive such 
a work to be useful, not only to students, but to 
practitioners as well. It reflects credit upon the 



Mi^?7 ^'^J ®^®''Sy °f ^t» able editor.-^osron 
Medxml atui Surgical Journal, Sept. 3, 1S74 

We can say with the strictest truth thai it i^ the 
Quann^ ?f ^^'l kind, with which we ai-e ac 
quainted. It embodies in a condensed form all 
thprpfnT*"?^/^"' *° practical medicine, and is 
out onr on?^f"' to every Wsy practitioner through- 
to hi Lr'i?*7'>^"!^^!.b«i"S admirably adapfed 



Pama. 



XEILL, JOHN, M. D., and SMITH, F. G., M. D 

lalc surgeon to tUePenna.nospital. P'of. of tke Lmitutes of M^. in „e V,J. . . r,-n,^ 

Scietce,fauJ*Leld^erSt'nS*sllfS' 'Pf"°"«Branches of Medical 

Inone,a.geroyan2nio.v,;;re':;nj^,^ 

LUDLOW, J. L., mTd^, 

Consulting Physician to the Plfiladclpliia nospital, etc. 

i» added .,. Medical Fon,,, l',™. T ; 'ed n 1 ' '„' 1 ^"" "'7^'l'«'f H^- , To which 

one l.„io. volnine of 8.0 ,,age, wittlji^i'S^it.^l^JlllS " noJit'lS!:! f iSltr' ^i^?'' '" 



4 Lea Brothers & Co.'s Publications — Dictionaries, 

BILLIKGS, J. S.f A. M.^ M.D.^ LL. JD., Saw. and Bdin., 

Member JSational Academy of Sciences, Surgeon U. S. A., etc, 
A MEDICAL DICTIONARY, including in one alphabet English, French, 
German, Italian and Latin Technical Terms used in Medicine and the Collateral 
Sciences, with accentuation and pronunciation of English words. By John S. Billings, 
A. M., M. D., LL. D. 

WITH THE COLLABORATION OF 

W. O. ATWATER. M. D., WASHINGTON MATTHEWS, M.D., 

FRANK BAKER, M. D., H. C. YARROW, M. D., 

JAMES M. FLINT, M. D., W. T. COUNCILMAN, M. D., 

R. LORINI, M.D., WILLIAM LEE, M.D., 

S. M. BURNETT, M. D., C. S. MINOT, M.D. 

J. H. KIDDER, M. D., 

In two very handsome royal octavo volumes. 

Shortly. Subscription only. Address the Publishers. 



jyVWGLISOW, MOBLBY, M.I}., 

Late Professor of Institutes of Medicine in the Jefferson Medical College of Philadelphia. 

MEDICAL LEXICON; A Dictionary of Medical Science: Containing 
a concise Explanation of the various Subjects and Terms of Anatomy, Physiology, Pathol- 
ogy, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Juris- 
prudence and Dentistry, Notices of Climate and of Mineral Waters, Formulae for Officinal, 
Empirical and Dietetic Preparations, with the Accentuation and Etymology of the Terms, 
and the French and other Synonymes, so as to constitute a French as well as an English 
Medical Lexicon. Edited by Eichard J. Dunglison, M. D. In one very large and 
handsome royal octavo volume of 1139 pages. Cloth, $6.50 ; leather, raised bands, $7.50 ; 
very handsome half Russia, raised bands, $8. 



About the first book purchased by the medical 
student is the Medical Dictionary. The lexicon 
explanatory of technical terms is simply a sine qua 
non. In a science so extensive and with such col- 
laterals as medicine, it is as much a necessity also 
to the practising physician. To meet the wants of 
students and most physicians the dictionary must 
be condensed while comprehensive, and practical 
while perspicacious. It was because Dunglison's 
met these indications that it became at once the 
dictionary of general use wherever medicine was 
studied in the English language. In no former 
revision have the alterations and additions been 
so great. The chief terms have been set in black 
letter, while the derivatives follow in small caps; 
an arrangement which greatly facilitates reference. 
— Cincinnati Lancet and Clinic, Jan. 10, 1874. 

A book of which every American ought to be 
proud. When the learned author of the work 



passed away, probably all of us feared lest the book 
should not maintain its place in the advancing 
science whose terms it defines. Fortunately, Dr. 
Richard J. Dunglison, having assisted his father in 
the revision of several editions of the work, and 
having been, therefore, trained in the methods 
and imbued with the spirit of the book, has been 
able to edit it as a work of the kind should be 
edited — to carry it on steadily, without jar or inter- 
ruption, along the grooves of thought it has trav- 
elled during its lifetime. To show the magnitude 
of the task which Dr. Dunglison has assumed and 
carried through, it is only necessary to state that 
more than six thousand new subjects have been 
added in the present edition. — Philadelphia Medical 
Times, Jan. 3, 1874. 

It has the rare merit that it certainly has no rival 
in the English language for accuracy and extent of 
references. — Londm Medical Gazette. 



MOBLYJ^, BICHAUiy D., M. B. 

A Dictionary of the Terms IJsed in Medicine and the Collateral 
Sciences. Revised, with numerous additions, by Isaac Hays, M. D., late editor of 
The American Journal of the Medical Sciences. In one large royal 12mo. volume of 520 
double-columned pages. Cloth, $1.50 ; leather, $2.00. 

It is the best book of definitions we have, and ought always to be upon the student's isAA^.— Southern 
Medical and Surgical Journal. 

STUDBNTS' SBBIBS OF MAWUALS. 

A Series of Fifteen Manuals, for the use of Students and Practitioners of Medicine 
and Surgery, written by eminent Teachers or Examiners, and issued in pocket-size 
12mo. volumes of 300-540 pages, richly illustrated and at a low price. The following vol- 
umes are now ready: Teeves' Manual of Surgery, by various writers, in three volumes, 
each, $2; Bell's Comparative Physiology and Anatomy, $2; Gould's Surgical Diagno- 
sis, $2 ; Robertson's Physiological Physics, $2 ; Bruce's Materia Medica and Therapeu- 
tics (4th edition), $1.50 ; Power's Human Physiology (2d edition), $1.50 ; Clarke and 
Lockwood's Dissector^ Manual, $1.50; Ralfe's Clinical Chemistry, $1.50; Treves* 
Surgical Applied Anatomy, $2 ; Pepper's Surgical Pathology, $2 ; and Klein's Elements of 
Histology (4th edition), $1.75. The following is in press : Pepper's Forensic Medicine. 
For separate notices see index on last page. 

SBBIBS OF CLINICAL MANUALS. 

In arranging for this Series it has been the design of the publishers to provide^ the 
profession with a collection of authoritative monographs on important clinical subjects 
in a cheap and portable form. The volumes will contain about 550 pages and will be 
freely illustrated by chromo-lithographs and woodcuts. The following volumes are 
now ready: Carter & Frost's Ophthalmic Surgery, $2.25; Hutchinson on Syphilis, 
^2.25 ; Ball on the Rectum and Anus, $2.25 ; Marsh on the Joints, $2 ; Owen on Surgical 
Diseases of Children, $2 ; Morris on Surgical Diseases of the Kidney, $2.25 ; Pick on 
Fractures and Dislocations, $2; Butlin on the Tongue, $3.50; Treves on Intestincd 
Obstruction, $2 ; and Savage on Insanity and Allied Neuroses, $2. The following are in 
active preparation: Broadbent on the Pulse, and Lucas on Diseases of the Urethra. 
For separate notices see index on last page. 



Lea Brothers & Co.'s Publications — Anatomy. 



GBAY, KBNBY, F. M. S., 

Lecturer on Anatomy at St. George's Hospital, London. 

Anatomy, Descriptive and Surgical. The Drawings by H. V. Carter, M. D., 
and Dr. Westmacott. The dissections jointly by the Author and Dr. Carter. With 
an Introduction on General Anatomy and Development by T. Holmes, M. A., Surgeon to 
St. George's Hospital. Edited by T. Pickering Pick, F. K. C. S., Surgeon to and Lecturer 
on Anatomy at St. George's Hospital, London, Examiner in Anatomy, Koyal College of 
Surgeons of England. A new American from the eleventh enlarged and improved London 
edition, thoroughly revised and re-edited by William W. Keen, M. D., Professor of 
Anatomy in the Pennsylvania Academy of the Fine Arts, etc. To which is added the 
second American from the latest English edition of Landmarks, Medical and Surgi- 
cal, by Luther Holden, F. E. C. S. In one imperial octavo volume of 1098 
pages, with 685 large and elaborate engravings on wood. Price of edition in black : 
Cloth, $6; leather, $7; half Eussia, $7.50. Price of edition in colors (see below): 
Cloth, $7.25; leather, $8.25; half Eussia, $8.75. 

This work covers a more extended range of subjects than is customary in the ordinary 
text-books, giving not only the details necessary for the student, but also the application to 
those details to the practice of medicine and surgery. It thus forms both a guide for the 
learner and an admirable work of reference for the active practitioner. The engravings 
form a special feature in the work, many of them being the size of nature, nearly all 
original, and having the names of the various parts printed on the body of the cut, in 
place of figures of reference with descriptions at the foot. In this edition a new departure 
has been taken by the issue of the work with the arteries, veins and nerves distinguished 
by difierent colors. The engravings thus form a complete and splendid series, which will 
greatly assist the student in forming a clear idea of Anatomy, and will also serve to refresh 
the memory of those who may find in the exigencies of practice the necessity of recall- 
ing the details of the dissecting-room. ' Combining, as it does, a complete Atlas of 
Anatomy with a thorough treatise on systematic, descriptive and applied Anatomy, 
the work will be found of great service to all physicians who receive students in their 
offices, relieving both preceptor and pupil of much labor in laying the groundwork of a 
thorough medical education. 

For the convenience of those who prefer not to pay the slight increase in cost necessi- 
tated by the use of colors, the volume is published also in black alone, and maintained 
in this style at the price of former editions, notwithstanding the largely increased size of 
the work. 

Landmarks, Medical and Surgical, by the distinguished Anatomist, Mr. Luther Holden, 
has been appended to the present edition as it was to the previous one. This work gives 
in a clear, condensed and systematic way all the information by which the practitioner can 
determine from the external surface of the body the position of internal parts. Thus 
complete, the work will furnish all the assistance that can be rendered by type and 
illustration in anatomical study. 



The most popular work on anatomy ever written. 
It is sufficient to say of it that this edition, thanks 
to its American editor, surpasses all other edi- 
tions.— Jour, of the Amer. Med. Ass^n, Dec. 31, 1887. 

A work which for more than twenty years has 
had the lead of all other text-books on anatomy 
throughout the civilized world comes to hand in 
such beauty of execution and accuracy of text 
and illustration as more than to make good the 
large promise of the prospectus. It would be in- 
deed difficult to name a feature wherein the pres- 
ent American edition of Gray could be mended 
or bettered, and it needs no prophet to see that 
the royal work is destined for many years to come 
to hold the first place among anatomical text- 



books. The work is published with black and 
colored plates. It is a marvel of book-making. — 
American Practitioner arid Neios, Jan. 21, 1SS8. 

Gray's Anatomy is the most magnificent work 
upon anatomy which has ever been published in 
the English or any other language. — Cincinnati 
Medical News, Nov. 1887. 

As the book now goes to the purchaser he Is re- 
ceiving the best work on anatomy that is j -'-'•'- - -■ 
in any language. — Virgin in Med. 

Gray's standard Anatoiny h&s been 'and will be 
for years the text-book for students. The book 
needs only to be examined to be perfectly under- 
stood. — Medical Press of Western Hew York, Jan. 



published 
MontMy,Dec. 1887. 



Also for sale separate — 
JEOLDBN, LVTHBB, F. B. C. S., 

Surgeon to St. Bartholomav's arid the Foundling Hospitals, London, 

Landmarks, Medical and SurgicaL Second American from the latest revised 
English edition, with additions by W. W. Keen, M. D., Professor of Artistic Anatomy in 
the Pennsylvania Academy of the Fine Arts, formerly Lecturer on Anatomy in the Phila- 
delphia School of Anatomy. In one handsome 12mo. volume of 14S pages'. Cloth, $1.00. 



This little book is all that can be desired within 
Its scope, and its contents will be found simply in- 
valuable to the young surgeon or physician, since 
they bring before hin\ sucmi data as he requires at 
every examination of a patient. It is written in 
language so clear and concise that one ought 
almost'to learn it by heart. It teaches diagnosis by 
external examination, ocular and palpable, of the 
body, with such anatomical and physiological facts 
as directly bear on the subject. It is eminently 
the student's and young practitioner's book.— P^V 
sician and Surgeon, Nov. 1881. 

The study of these Landmarks by both physi- 



cians and surgeons is much to be encouraged. It 
inevitably loads to a progressive oducationVf l>oth 
the^ye and the toucn,by which the recognition of 
disease or the localization of injuries is va^Jtly as- 
sisted. One thoroughly familiar with the facts here 
taught is capable of a degree of accuracy and a 
coutidence of certainty which is otherwise unat- 
tainable. Wo cordiallyVecommond the Landmarks 
to the attention of o'vory physician who h.-is not 
yet provided himself with a copv of this useAil, 
practical girido to the correct plsicing of all the 
anatomical parts and orgaus.— C<»'»rtda Jifedico/and 
Surgical Jour'tml, Deo. ISSl. 



6 Lea Brothers & Co.'s Publications — Anatomy, 

ALLEW, MABBISON, M. !>., 

Professor of Physiology in the University of Pennsylvania,. 

A System of Human Anatomy, Including Its Medical and Surgical 
Relations. For the use of Practitioners and Students of Medicine. With an Intro- 
ductory Section on Histology. By E. O. Shakespeahe, M. D., Ophthalmologist to 
the Philadelphia Hospital. Comprising 813 double-columned quarto pages, with 380 
illustrations on 109 full page lithographic plates, many of which are in colors, and 241 
engravings in the text. In six Sections, each in a portfolio. Section I. Histology. 
Section II. Bones and Joints. Section III. Muscles and Fascia. Section IV. 
Arteries, Veins and Lymphatics. Section V. Nervous System. Section VI. 
Organs of Sense, op Digestion and Genito-Urinary Organs, Embryology, 
Development, Teratology, Superficial Anatomy, Post-Mortem Examinations, 
AND General and Clinical Indexes. Price per Section, $3.50 ; also bound in one 
volume, cloth, $23.00 ; very handsome half Russia, raised bands and open back, $25.00. 
For sale by subscription only. Apply to the Publishers. 

care, and are simply superb. There is as much 



It is to De considered a study of applied anatomy 
In its widest sense— a systematic presentation of 
such anatomical facts as can be applied to the 
practice of medicine as well as of surgery. Our 
author is concise, accurate and practical in his 
statements, and succeeds admirably in infusing 
an interest into the study of what is generally con- 
sidered a dry subject. The department of Histol- 
ogy is treated in a masterly manner, and the 
ground is travelled over by one thoroughly famil- 
iar with it. The illustrations are made witn great 



of practical application of anatomical points to 
the every-day wants of the medical clinician as 
to those of the operating surgeon. In fact, few 
general practitioners will read the work without a 
feeling of surprised gratification that so many 
points, concerning which they may never have 
thought before are so well presented for their con- 
sideration. It is a work which is destined to be 
the best of its kind in any language.— Medical 
Record, Nov. 25, 1882. 



CLABKB, W. B., F.B. C.S. & LOCKWOOD, C. B., F.B. C.S. 

Demonstrators of Anatomy at St. Bartholomew's Hospital Medical School, London. 
The pissector's Manual. In one pocket-size 12mo. volume of 396 pages, with 
49 illustrations. Limp cloth, red edges, $1.50. See Student^ Series of Manuals, page 4. 

intimate association with students could have 

fiven. With such a guide as this, accompanied 
y so attractive a commentary as Treves' Surgical 
Applied Anatomy (same series), no student could 
fail to be deeply and absorbingly interested in the 
study of anatomy.— iV^ew; Orleans Medical am Sur- 
gical Journal, April, 1884. 



Messrs.Clarke and Lockwood have written a book 
that can hardly be rivalled as a practical aid to the 
dissector. Their purpose, which is "how to de- 
scribe the best way to display the anatomical 
structure," has been fully attained. They excel in 
a lucidity of demonstration and graphic terseness 
of expression, which only a long training and 



TBMVBS, FBBDBBICK, F. B. C. S., 

Senior Demo'ostrator of Anatomy and Assistant Surgeon at the London Hospital, 
Surgical Applied. Anatomy. In one pocket-size 12mo. volume of 540 pages, 
with 61 illustrations. Limp cloth, red edges, $2.00. See Students' Series of ManualSy 
page 4. 



He has produced a work which will command a 
larger circle of readers than the class for which it 
was written. This union of a thorough, practical 
acquaintance with these fundamental branches, 
quickened by daily use as a teacher and practi- 
tioner, has enabled our author to prepare a work 
which it would be a most difficult task to excel.— 
The American Practitioner, Feb. 1884. 



This number of the " Manuals for Students " is 
most excellent, giving just such practical knowl- 
edge as will be required for application in relieving 
the injuries to which the living body is liable. 
The book is intended mainly for students, but it 
will also be of great use to practitioners. The illus- 
trations are well executed and fully elucidate the 
text, — Southern Practitioner, Feb, 1884. 



BELLAMY, FL>WABL>, F. B. C. S., 

Senior Assistant-Surgeon to the Charing-Cross Hospital, London. 

The Student's Guide to Surgical Anatomy: Being a Description of the 
most Important Surgical Kegions of the Human Body, and intended as an Introduction to 
operative Surgery. In one 12mo. volume of 300 pages, with 50 illustrations. Cloth, $2.25^ 

WILSON, FBASMUS, F. B. S. 

A System of Human Anatomy, General and Special. Edited by W, H. 
GoBRECHT, M. D., Professor of General and Surgical Anatomy in the Medical College ol 
Ohio. In one large and handsome octavo volume of 616 pages, with 397 illustrations. 
Cloth, $4.00; leather, $5.00. 

CLFLAJSrU, JOHN, M. J>., F. B. S,, 

Professor of Anatomy and Physiology in Queen's College, QaCway, 

A Directory for the Dissection of the Human Body. In one 12mo. 
volume of 178 pages. Cloth, $1.25. 



HARTSHORNE'S HANDBOOK OF ANATOMY 
AND PHYSIOLOGY. Second edition, revised. 
In one royal 12mo. volume of 310 pages, with 220 
woodcuts. Cloth, $1.75. 



HORNER'S SPECIAL ANATOMY AND HISTOL- 
OGY. Eighth edition, extensively revised and 
modified. In two octavo volumes of 1007 pagea^ 
with 32U woodcuts. Cloth, gti.ou. 



Lea Brothers & Co.'s Publications — Physics, Pliysiol.jAnat. 



nnAPER, JOHN C, 31. JD.y LL, !>., 

Profeaiior of Chemistry in the University of the City of New York. 
Medical Physics. A Text-book for Students and Practitioners of Medicine. In 
one octavo volume of 734 i)ages, with 376 woodcuts, mostly original. Cloth, $4. 

FROM THE PREFACE. 

The fact that a knowledge of Physics is indispensable to a tliorough understanding of 
Medicine has not been as fully realized in this country as in Europe, where the admirable 
works of Desplats and Gariel, of Robertson and of numerous German writers constitute a 
branch of educational literature to which we can show no parallel, A full appreciation 
of this the author trusts will be sufficient justification for placing in book form the sub- 
stance of his lectures on this department of science, delivered during many years at the 
University of tiie City of JS'ew York. 

Broadly si)eaking, this work aims to impart a knowledge of the relations existing 
between Physics and Medicine in their latest state of development, and to embody in the 
pursuit of this object whatever experience the author has gained during a long period of 
leaching this special branch of applied science. 

This elegant and useful work bears ample testi- 
mony to tlie learning and good judgment of the 
author. JJe has fitted his work admirably to the 
exigencies of the situation by presenting the 
reader with brief, clear and simple statements of 



euch propositions as he is by necessity required to 
master. The subject matter is well arranged, 
liberally illustrated and carefully indexed. That 
it will take rank at once among the text-books is 
certain, and it is to be lioped that it will find a 
place upon the shelf of the practical physician, 
where, as a book of reference, it will be found 
useful and agreeable.— XouisviWe Medical News, 
September 2G, 1885. 

Certainly we have no text-book as full as the ex- 
eellent one he has prepared. It begins with a 
statement of the properties of matter and energy. 
After these the special departments of i)hysics are 



explained, acoustics, optics, heat, electricity and 
magnetism, closing with a section on electro- 
biology. The applications of all these to physiology 
and medicine are kept constantly in view. The 
text is amply illustrated and the many difficult 
points of the subject are brought forward with re- 
markable clearness and ability. — Medical and Surg- 
ical Reporter, July 18, 1885. 

That this work will greatly facilitate the study 
of medical physics is apparent upon even a mere 
cursory examination. It is marked by that scien- 
tific accuracy which always characterizes Dr. 
Draper's writings. Its peculiar value lies in the 
fact that it is written from the standpoint of the 
medical man. Hence much is omitted that ap- 
pears in a mere treatise on physical science, while 
much is inserted of peculiar value to the physi- 
cian. — Medical Record, August 22, 1885. 



MOBEnTSOW, J. McGMBGOB, M. A., M. B., 

Muirhead Deinonstrator of Physiology, University of Glasgow. 
Physiological Physics. In one 12mo, volume of 537 pages, with 219 illustw 
tions. Limp cloth, $2.00. See Students' Series of Manuals, page 4. 

The title of this work sufficiently explains the 
nature of its contents. It is designed as a man- 
ual for the student of medicine, an auxiliary to 
his text-book in physiology, and it would be particu- 
larly useful as a guide to his laboratory experi- 



ments. It will be found of great value to the 
practitioner. It is a carefully prepared book of 
reference, concise and accurate, and as such we 
heartily recommend it.— Journal of the Avuruum 
Medical Association, Dec. G, 1884. 



JDALTOJSr, JOMJSr €., M. D., 

Professor Emeritus of Physiology in tJie College of Physicians and Surgeons, New York. 

Doctrines of the Circulation of the Blood. A History of Physiological 
Opinion and Discovery in regard to the Circulation of the Blood. In one handsome 
12mo. volume of 293 pages. Cloth, $2. 



Dr. Dal ton's work is the fruit of the deep research 
of a cultured mind, and to the busy practitioner it 
cannot fail to be a source of instruction. It will 
inspire him with a feeling of gratitude and admir- 
ation for those plodding workers of olden times, 
who laid the foundation of the magnificent temple 
of medical scioncp as it now stands. — New Orleans 
AJidicnl and Surgical Journal, Aug. 1885. 

In the progress of physiological study no fact 
was of greater moment, none more completely 



revolutionized the theories of teachers, than the 
discovery of the circulation of the blood. This 
explains the extraordinary interest it has to all 
medical historians. The volume before us is one 
of three or four which have been written within a 
few years by Amerioan physicians. It is in several 
respects the most complete. The volume, thoujjh 
small in size, is one of the most creditable con- 
tributions from an American pen to medical history 
that has appeared.— 3/etf. <i Surg. Rep., Dec. tj, 1884. 



BELL, F, JEFFREY, M. A., 

Professor (f Comparative Anatomy at King's College, London. 

Comparative Physiology and Anatomy. In one r2mo. volume of 561 pagea, 
with 229 i I lustrations. Limp cloth, $2.00. See Students' Sci^ics of ^[an^tx^h, page 4. 

The manual is preeminently a student's book — it the best work in cxistem^e in the English 
dear and simple in language and arrangement. 
It is well and abundantly illustrated, and is road- 
Able and intort-sting. On the whole we consider 



exi 

language to place in the hand<* of the mediC4J 
student— .Brfcs<t>i Medico-Chirurgicai Journal, Mar. 
188(5. 



ELLIS, GEORGE VIJSTER, 

Emeritus Professor </ Auntoiny in University College, London, 

Demonstrations of Anatomy. IkMug a (luide to the Knowleiljre of the 
Humnn llody by Dissection. Fron\ the eighth and revist\l Loiulon eilition. In one very 
liandsomc octavo volume of 715 pages, with 249 illustrations. Cloth, $4.2-3 ; leather, $o.26. 

ROBERTS, JOHN^B., A. M., M. J>., 

prof, of Ap/ilicd Anat. and Oper. Surg, in Phila. Polyclinic and Coll. fo^- QraduatfS in -VftiiWfWi. 

The Compend of Anatomy. For use in the dissect ing-rvH>m and iu preiuiring 
for examinations. In one IGiuo. volume of 19t> pages. Limp cloth, 75 cents. 



8 Lea Brothers & Co.'s Publications — Physiology, Chemistry, 



cma:pman, henby a, ii. n., 

Professor of Institutes of Medicine and Medical Juris, in the Jefferson Med. Coll. of Philadelphia. 

A Treatise on Human Physiology. In one handsome octavo volume of 
925 pages, with 605 fine engravings. Cloth, $5.50; leather, $6.50. 



It represents very fully the existing state of 
physiology. The present work has a special value 
to the student and practitioner as devoted more 
to the practical application of well-known truths 
which the advance of science has given to the 
profession in this department, which may be con- 
sidered the foundation of rational medicine. — Buf- 
falo Medical and Surgical Journal, Dec.l8S7. 

Matters which have a practical bearing on the 
practice of medicine are lucidly expressed; tech- 
nical matters are given in minute detail; elabo- 
rate directions are stated for the guidance of stu- 
dents In the laboratory. In every respect the 
work fulfils its promise, whether as a complete 
treatise for the student or for the physician ; for 
the former it is so complete that he need look no 



farther, and the latter will find entertainment and 
instruction in an admirable book of reference. — 
North Carolina Medical Journal, Nov. 1887. 

The work certainly commends itself to both 
student and practitioner. What is most demanded 
by the progressive physician of to-day is an adap- 
tation of physiology to practical therapeutics, and 
this work is a decided improvement in this respect 
over other works in the market. It will certainly 
take place among the most valuable text-books. — 
Medical Age, Nov. 25, 1887. 

It is the production of an author delighted with 
his work, and able to inspire students with an en- 
thusiasm akin to his own. — American Practitioner 
and News, Nov. 12, 1887. 



JDAZTOW, JOSN a, M. D., 

Professor of Physiology in the College of Physicians and Surgeons, New York, etc. 
A Treatise on Human Physiology. Designed for the use of Students and 
Practitioners of Medicine. Seventh edition, thoroughly revised and rewritten. In one 
very handsome octavo volume of 722 pages, with 252 beautiful engravings on wood. Cloth, 
$5.00; leather, $6.00. 



From the first appearance of the book it has 
been a favorite, owing as well to the author's 
renown as an oral teacher as to the charm of 
simplicity with which, as a writer, he always 
succeeds in investing even intricate subjects. 
It must be gratifying to him to observe the fre- 
quency with which his work, written for students 
and practitioners, is quoted by other writers on 
physiology. This fact attests its value, and, in 
great measure, its originality. It now needs no 
such seal of approbation, however, for the thou- 
sands who have studied it in its various editions 



have never been in any doubt as to its sterling 
worth.— iV. Y. Medical Journal, Oct. 1882. 

Professor Dalton's well-known and deservedly- 
appreciated work has long passed the stage at 
which it could be reviewed in the ordinary sense. 
The work is eminently one for the medical prac- 
titioner, since it treats most fully of those branches 
of physiology which have a direct bearing on the 
diagnosis and treatment of disease. The work is 
one which we can highly recommend to all our 
leadeis.— Dublin Journal of Medical Science, Feb.'83. 



JFOSTEB, MICSABL, M. D., F. M. S., 

Prelector in Physiology and Fellow of Trinity College, Cambridge, England. 
Text-Book of Physiology. New (fourth) American from the fifth and revised 
English edition, with notes and additions by E. T. Eeichert, M. D., Professor of Physi- 
ology in University of Pennsylvania. Preparing. 

A REVIEW OF THE FIFTH ENGLISH EDITION IS APPENDED. 

tions, and his energies are not frittered away and 
degenerated on petty and trivial details. Review- 
ing this volume as a whole we are justified in say- 
ing that it is the only thoroughly good text-book 
of physiology in the English language, and that it 
is probably the best text-book in any language. 
—Edinburgh Medical Journal, December 1888. 



It is delightful to meet a book which deserves 
only unqualified praise. Such a book is now before 
us. It is in all respects an ideal text-book. With a 
complete, accurate and detailed knovvledge of his 
subject, the author has succeeded in giving a 
thoroughly consecutive and philosophic account 
of the science. A student's attention is kept 
throughout fixed on the great and salient ques- 



POWJEIt, SBJSTtT, M. B., F. B. C. S., 

Examiner in Physiology, Royal College of Surgeons of England. 
Human Physiology. Second edition. In one handsome pocket-size 12mo. vol- 
ume of 396 pp., with 47 illustrations. Cloth, $1.50. See Students' Series of Manuals, p. 4. 

SIMON, W., Fh. !>., M. 2>., 

Professor of Chemistry and Toxicology in the College of Physicians and Surgeons, Baltimore, and 
Professor of Chemistry in the Maryland College of Pharmacy. 

Manual of Chemistry. A Guide to Lectures and Laboratory work for Beginners 
in Chemistry. A Text-book, specially adapted for Students of Pharmacy and Medicine. 
New (second) edition. In one 8vo. vol. of 478 pp., with 44 woodcuts and 7 colored plates 
illustrating 56 of the most important chemical tests. Just ready. Cloth, $3.25. 

FROM THE PREFACE. 

It has been the aim of the Author to present a work on general chemistry which may be used to 
advantage as a text-book by beginners, aad which, at the same time, covers the special needs of the 
medical and pharmaceutical student. While the general character of the second edition is the same 
as that of the first, many changes and numerous additions have been made with the view of render- 
ing the work more complete and useful. For the special benefit of pharmaceutical and medical stu- 
dents all chemicals mentioned in the United States Pharmacopoeia are included, and when of sufficient 
interest, are fully considered. Having frequently noticed the difficulty experienced by beginners in 
becoming familiar with the variously shaded colors of chemicals and their reactions, the Author 
decided to illustrate the work with a number of plates, presenting the colors of those most important. 

Wohler's Outlines of Organic Chemistry. Edited by Fittig. Translated 
by Ira Eemsen, M. D., Ph. D. In one 12mo. volume of 550 pages. Cloth, $3. 



LEHMANN'S MANUAL OF CHEMICAL PHYS- 
IOLOGY. In one octavo volume of 327 pages, 
with 41 illustrations. Clofh, S2.25. 

CARPENTER'S HUMAN PHYSIOLOGY. Edited 
by Henby Poweb. In one octavo volume. 



CARPENTER'S PRIZE ESSAY ON THE USE AND 
Abuse of Alcoholic Liquobs in Health and Dis- 
ease. "With explanations of scientific words. Small 
12mo. 178 pages. Cloth, 60 cents. 



Lea Brothers & Co.'s Publications — Chemistry* 



FBANKLANn, jE7., B. C. i., F.B.S., &JABP, F. JR., F I. C, 



Professor of Chemistry in the Normal School 
of Science, London. 



Assist. Prof, of Chemistry in the Normal 
School of Science, London. 



Inorganic Chemistry. In one handsome octavo volume of 677 pages with 51 

woodcuts and 2 plates. Cloth, $3.75 ; leather, $4.75. 



This work should supersede other works of its 
class in the medical colleges. It is certainly better 
adapted than any work upon chemistry,with which 
we are acquainted, to impart that clear and fall 
knowledge of the science which students of med- 
icine should have. Physicians who feel that their 
chemical knowledge is behind the times, would 
do well to devote some of their leisure time to the 
study of this work. The descriptions and demon- 
strations are made so plain that there is no diffi- 
culty in understanding them. — Cincinnati Medical 
News, January, 1886. 



This excellent treatise will not fail to take its 
place as one of the very best on the subject of 
which it treats. We have been much pleased 
with the comprehensive and lucid manner in 
which the difficulties of chemical notation and 
nomenclature have been cleared up by the writers. 
It shows on every i>age that the problem of 
rendering the obscurities of this science easy 
of comprehension has long and successfully 
engaged the attention of the authors. — Medical 
and Surgical Reporter, October 31, 1885. 



FOWNMS, GFOBGF, Bh. JD. 

A Manual of Elementary Chemistry; Theoretical and Practical. Em- 
bodying Watts' Physical Inorganic Chemistry. New American, from the twelfth English 
edition. In one large royal 12mo. volume of 1061 pages, with 168 illustrations on wood 
and a colored plate. Cloth, $2.75 ; leather, $3.25. 
Fownes* Chemistry has been a standard text- 



book upon chemistry for many years. Its merits 
Rre very fulljr known by chemists and physicians 
everywhere m this country and in England. As 
the science has advanced by the making of new 
discoveries, the work has beeu revised so as to 
keep it abreast of the times. It has steadily 
maintained its position as a text-book with medi- 
cal students. In this work are treated fully: Heat, 
Light and Electricity, including Magnetism. The 
influence exerted by these forces in chemical 
action upon health and disease, etc., is of the most 
Important kind, and should be familiar to every 
medical practitioner. We can commend the 
work as one of the very best text-books upon 



chemistry extant. — Cincinnati Medical News, Oc- 
tober, 1885. 

Of all the works on chemistry intended for the 
use of medical students, Fownes' Chemistry is 

Eerhaps the most widely used. Its popularity is 
ased upon its excellence. This last edition con- 
tains all of the material found in the previous, 
and it is also enriched by the addition of Watts' 
Physical and Inorganic Chemistry. All of the mat- 
ter is brought to the present standpoint of chemi- 
cal knowledge. We may safely predict for this 
work a continuance of the fame and favor it enjoys 
among medical students. — New Orleans Medical 
and Surgical Journal, March, 1886. 



ATTFIELB, JOSN, Fh. 2>., 

Professor of Practical Chemistry to the Pharmaceutical Society of Oreat Britain, etc 

Chemistry, General, Medical and Pharmaceutical; Including the Chem- 
istry of the U. S. Pharmacopoeia. A Manual of the General Principles of the Science, 
and their Application to Medicine and Pharmacy. A new American, from the twelfth 
English edition, specially revised by the Author for America. In one handsome royal 
12mo. volume of about 750 pages, with about 100 illustrations. In press. 

A notice of the previous edition is appended. 

in sixteen years must have good qualities. It 



It is a book on which too much praise cannot be 
bestowed. As a text-book for medical schools it 
Is unsurpassable in the present state of chemical 
science, and having been prepared with a special 
view towards medicine and pharmacjr, it is alike 
indispensable to all persons engaged in those de- 
partments of science. It includes the whole 
chemistry of the last Pharmacopoeia. — Pacific Medi- 
cal and Surgical Journal, Jan. 1884. 

A text-book which passes through ten editions 



seems desirable to point out that feature of the 
book which, in all probability, has made it so 
popular. There can be little doubt that it is its 
thoroughly practical character, the expression 
being used in its best sense. Tne author under- 
stands what the student ought to learn, and is able 
to put himself in the student's place and to appre- 
ciate his state of min±— -American Chemical Jour* 
nal, April, 1884. 



BLOXAM, CHABLF8 X., 

Professor of Chemistry in King's College, London. 
Chemistry, Inorganic and Organic. New American from the fifth Lon- 
don edition, thoroughly revised and much improved. In one very handsome octavo 
volume of 727 pages, with 292 illustrations. Cloth, $2.00 ; leather, $3.00. 



Comment from us on this standard work is al- 
most superfluous. It differs widely in scope and 
aim from that of Attfield, and in its way is equally 
beyond criticism. It adopts the most direct meth- 
ods in stating the principles, hypotheses and facts 
of the science. Its language is so terse and lucid, 
and its arrangement of matter so logical in se- 
quence that tne student never has occasion to 
complain that chemistry is a hard study. Much 
attention is paid to experimental Illustrations o( 
chemical principles and phenomena, and the 
mode of conductinc those experiments. The book 
maintains the position it has always held as one of 



the best manuals of general chemistry tn the Eng- 
lish language. — Detroit Lancet, Feb. 1SS4. 

We know of no treatise on chemistry which 
contains so much practical information in the 
same number of pages. The book can be readily 
adapted not only to the needs of those who desire 
a tolerably complete course of chemistry, but also 
to the needs of those who desire only a general 
knowledge of the subject. We take pleasure in 
recommending this work both as a satisfactory 
text-book, and as a useful book of reference.— £o>. 
ton Medical ami Surgical Juurruii, June Id, 1&54, 



GBFFKB, WILLIAM H., M. J)., 

Demonstrator of Chcmistn/ in the Medical Department of the University of PetmsvlvanUL 

A Manual of Medical Chemistry. For the use of Students. Baseil ujn^n Bow« 
man's IMedical Chemistry. In one V2n\o. volume of 810 pages, with 74 illus. Cloth, if 1.75. 
It Is a concise manual of three hundred pages, I the recognition of compounds due to pathological 
giving an excolient summary of the best methods conditions. The detection of poisons is treated 
of analyzing the liquids and solids of the body, both with sutttcient fulness for the purjH->se of thesto- 
for the estimation of their normal constituents and 1 dent or practitioner.— £o»f(.m JL of Chetn, Jane,*80. 



10 



Lea Brothers & Co.'s Publications — Chemistry. 



REMSEN, IMA, M. D., JPh, J}., 

Professor of Chemistry in the Johns Hopkins University, Baltimore' 
Principles of Theoretical Chemistry, with special reference to the Constitu- 
tion of Chemical Compounds. New (third) and thoroughly revised edition. In one hand- 
some royal 12mo. volume of 316 pages. Cloth, ^2.00 

This work of Dr. Remsen is the yery text-book I examination of college facalties as ifte text-book o£ 
needed, and -the medical student who has it at j chemical instruction.— S^. Louis Medical and Sur- 
his fingers' ends, so to speak, can, if he chooses, i gical Journal, January, 1888. 

make himself familiar with any branch of ehem- [ It is a healthful sign when we see a demand for 
islry which he may desire to pursue. It would be a third edition of such a book as this. This edi- 
difficult indeed to find a more lucid, full, and at tion is larger than the last by about seventy-five- 



the same time compact explication of the philos- 
ophy of chemistry, than the book before us, and 
we recommend it to the careful and impartial 



>ages, and much of it has been rewritten, thus 
)ringing it fully abreast of the latest investiga* 
tions.— iV. Y. Medical Journal, Dec. 31, 1887. 



CHARLES, T. CRANSTOUN, M. !>., F. C. S., M. S., 

Formerly Asst. Prof, and Demonst. of Chemistry and Chemical Physics, Queen's College, Belfast. 

The Elements of Physiological and Pathological Chemistry. A 

Handbook for Medical Students and Practitioners. Containing a general account of 
Nutrition, Foods and Digestion, and the Chemistry of the Tissues, Organs, Secretions and 
Excretions of the Body in Health and in Disease. Together with the methods for pre- 
paring or separating their chief constituents, as also for their examination in detail, and 
an outline syllabus of a practical course of instruction for students. In one handsome octavo- 
volume of 463 pages, with 38 woodcuts and 1 colored plate. Cloth, $3.50. 

Dr. Charles is fully impressed with the import- 
ance and practical reach of his subject, and he 
has treated it in a competent and instructive man- 
ner. We cannot recommend a better book than 
the present. In fact, it fills a gap in medical text- 
books, and that is a thing which can rarely be said 



nowadays. Dr. Charles has devoted much space 
to the elucidation of urinary mysteries. He does 
this with much detail, and yet in a practical and 
intelligible manner. In fact, the author has filled 
his book with many practical hints.— Medical Rec- 
ord, December 20, 1884. 



HOFFMAJSlSr, F., A.M.,JPh.I)., <& FOWEB F.B., Fh.D., 

Public Analyst to the State of New York. Prof, of Anal. Chem. in the Phil. Coll. of Pharmacy. 

A Manual of Chemical Analysis, as applied to the Examination of Medicinal 
Chemicals and their Preparations. Being a Guide for the Determination of their Identity 
and Quality, and for the Detection of Impurities and Adulterations. For the use of 
Pharmacists, Physicians, Druggists and Manufacturing Chemists, and Pharmaceutical and 
Medical Students. Third edition, entirely rewritten and much enlarged. In one ven 
handsome octavo volume of 621 pages, with 179 illustrations. Cloth, $4.25. 

We congratulate the author on the appearance 
of the third edition of this work, i)ublished for the 
first time in this country also. It is admirable and 



Jry 

Ihe information it undertakes to supply is both 
extensive and trustworthy. The selection of pro- 
cesses for determining the purity of the substan- 
ces of which it treats is excellent and the descrip- 



tion of them singularly explicit. Moreover, it is- 
exceptionally free from typographical errors. "We- 
have no hesitation in recommending it to those- 
who are engaged either in the manufacture or the 
testing of medicinal chemicals. — London Pharma^ 
ceutical Journal and Transactions, 1883. 



CLOWES, FHAJVE:, n. Sc, London, 

Senior Science- Master at the High School, Newcastle-under-Lyme, etc. 

An Elementary Treatise on Practical Chemistry and Qualitative 
Inorganic Analysis. Specially adapted for use in the Laboratories of Schools and 
Colleges and by Beginners. Third American from the fourth and revised English edition. 
In one very handsome royal 12mo. volume of 387 pages, with 55 illustrations. Cloth> 
$2.50. 



This work has long been a favorite with labora- 
tory instructors on account of its systematic plan, 
carrying the student st*p by step from the simplest 
questions of chemical analysis, to the more recon- 
dite problems. Features quite as commendable 
are the regularity and system demanded of the 



student in the performance of each analysis.. 
These characteristics are preserved in the present 
edition, which we can heartily recommend as a sat- 
isfactory guide for the student of inorganic chem- 
ical analysis. — New York Medical Journal, Oct. 9,, 



BALFE, CMABLES FT., M. D., F. M. C. F., 

Assistant Physician at the London Hospital. 
Clinical Chemistry. In one pocket-size 12mo. volume of 314 pages, with 

See Students' Series of Manuals, page 4. 



16 



illustrations. Limp cloth, red edges, $1.50 
This is one of the most instructive little works 
that we have met with in a long time. The author 
is a physician and physiologist, as well as a chem- 
ist, consequently the book is unqualifiedly prac- 
tical, telling the physician just what he ougnt to 
know, of the applications of chemistry in medi- 



cine. Dr. Ralfe is thoroughly acquainted with the- 
latest contributions to his science, and it is quite- 
refreshing to find the subject dealt with so clearly 
and simply, yet in such evident harmony with the 
modern scientific methods and spirit.— ilfedtcrl" 
Record, February 2, 1884. 



CLASSEN, ALEXAJS^DEB, 

Professor in the Royal Polytechnic School, Aix-la-Chapelle. 

Elementary Quantitative Analysis. Translated, with notes and additions, by 
Edgas F. Smith. Ph. D., Assistant Professor of Chemistry in the Towne Scientific School, 
University of Penna. In one 12mo. volume of 324 images, with 36 illus. Cloth, $2.00. 

It is probably the best manual of an elementary and then advancing to the analysis of rninerals and 
nature extant, insomuch as its methods are the such products as are met with in applied chemis- 
best. It leaches by examples, commencing with try. It is an indispensable book for students in> 
single determinations, followed by separations, chemistvy.— Boston Journal of Chemistry, Oct. 1818.. 



Lea Brothers & Co.'s Publications — Pharm., Mat. Med., Therap. 11 



BBVNTOJS^, T. LATinEB, M.D., D.Sc, F.M.S., F.R.C.JP., 

Lecturer on Materia Medica and Therapeutics at St. Bartholomew's Hospital, London, etc. 

A Text-book of Pharmacology, Therapeutics and Materia Medica ; 

Including the Pharmacy, the Physiological Action and the Therapeutical Uses of Drugs. 
New (3d) edition. Octavo, 1305 pages, 230 illustrations. Cloth, $5.50 ; leather, $6.50. 



No words of praise are needed for this work, for 
it has already spoken for itself in former editions. 
It was by unanimous consent placed among the 
foremost books on the subject ever published in 
any Ian guage, an d the better it is known and studied 
the more highly it is appreciated. The present 
edition contains much new matter, the insertion 
of which has been necessitated by the advances 
made in various directions in the art of therapeu- 
tics, and it now stands unrivalled in its thoroughly 
scientific presentation of the modes of drug action. 
l^o one who wishes to be fully up to the times in 
this science can afford to neglect the study of Dr. 
Brunton's work. The indexes are excellent, and 
add not a little to the practical value of the book. 
— Medical Record, May 25, 1889. 

Nothing so original and so complete on the action 
of drugs on the body generally and on its various 



parts, has appeared during the life of the present 
generation. This is strong language, but it is the 
truth. The great merit of this work is that tho 
author has been able so well to coordinate facts 
into an intelligible and rational system of pharma- 
cology, and henceforth no treatise on therapeutics 
will be considered complete which does not in 
some measure adopt this method. The busy 
physician will approach this book to learn some- 
thing that will better fit him for his work, and on 
every page he will find something that will reward 
him for the time spent in its perusal. W^e com- 
mend this book as one which every physician 
should own and study. It is a work which if once 
owned will be likely to be read and consulted till 
the covers fall off" from much use. — Boston Medical 
and Surgical Journal, Dec. 20, 1888. 



MAISCS, JOSJSTM., PJiar. D., 

Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy. 

A Manual of Organic Materia Medica; Being a Guide to Materia Medica of 
the Vegetable and Animal Kingdoms. For the use of Students, Druggists, Pharmacists 
and Physicians. New ('3d) edition, thoroughly revised. In one handsome royal 12mo. 
volume of 523 pages, with 257 illustrations. Cloth, |3. 

author are a guarantee that his manual is well 
adapted for its purpose, viz. : a text- and reference- 
book for students, pharmacists and physicians, con- 
taining the most recent and reliable information 
in regard to drugs. — Cincinnati Med. News,^OY. 1887. 



Prof. Maisch is one of the most distinguished 
pharmacists of this country. He and Prof. Stille 
are the authors of The National Dispensatory, 
which is not excelled by any work of its kind ever 
published. The learning and experience of the 



BAMTMOLOW, ItOBBMTS, A. M., M. jD., LL. £>., 

Professor of Materia Medica and General Therapeutics in the Jefferson Med. Coll. of Philadelphia 

New Remedies of Indigenous Source: Their Physiological Actions and 
Therapeutical Uses. In one octavo volume of about 300 pages. Preparing. 



I'AMBISS, EnwABn, 

Late Professor of the Theory and Practice of Pharmacy in the Philadelphia College of Pharmacy. 
A Treatise on Pharmacy : designed as a Text-book for the Student, and as a 
Guide for the Physician and Pharmaceutist. With many Formulae and Prescriptions. 
Fifth edition, thoroughly revised, by Thomas S. Wieqand, Ph. G. In one handsome 
octavo volume of 1093 pages, with 256 illustrations. Cloth, $5 ; leather, 

There is nothing to equal Parrish's Pharmacy 
in this or any other language.— iondon Pharmon 
ceutical Journal. 



No thorough-going pharmacist will fail to possess 
himself of so useful a guide to practice, and no 
physician who properly estimates the value of an 
accurate knowledge of the remedial agents em- 
ployed by him in daily practice, so far as their 
miscibility, compatibility and mosteffective meth- 
ods of combination are concerned, can afford to 
leave this work out of the list of their works of 



reference. The country practitioner, who must 
always be in a measure his own pharmacist, will 
find it indispensable. — Louisville Medical Neios, 
March 29, 1884. 

All that relates to practical pharmacy — apparatus, 
processes and dispensing— has been arranged ancl 
described with clearness in its various aspects, so 
as to afford aid and advice alike to the student and 
to the practical pharmacist. The work is judi- 
ciously illustrated with good woodcuts — Anierican 
Journal of Pharmacy, January, 1884. 



Professor of Physiology in the University of Zurich. 
Experimental Pharmacology. A Handbook of Methods for Determining the 
Physiological Actions of Drugs. Translated, with the Author's permission, and with 
extensive additions, by Robert Meade Smith, M. D., Demonstrator of Physiology in the 
University of Pennsylvania. 12mo., 199 pages, with 32 illustrations. Cloth, $1.50. 

BRUCE, J. MITCHELL, M. n., F. B. C. P., 

Physician and Lecturer on Materia Medica ami Therapeutics at Charing O'oss Hospital^ London. 
Materia Medica and Therapeutics. An Introduction to Rational Treatment. 
Fourth edition. 12mo., 591 pages. Cloth, $1.50. See StudeTiL^' Sei^ies of Manuals, juge 4. 

STILLE, ALFBEn, M. D., LL.^^ 

Professor of Theory and Practice of Med. and of Clinical Med. in the Univ. of Pen no. 

Therapeutics and M^ateria Medica. A Systematic Treatise on the Action and 
Uses of Medicinal Agents, iacluding their Description and History, Fourth eiiition, 
revised and enlarged. In two large and handsome octavo volumes, containing 1936 luigea. 
Cloth, $10.00; leather, $12.00. 

GBIFFITH, BOBEBT EGLESFIELD, Jf. D. 

A Universal Formulary, amt^iining the Metluxls of Preparing and Adminis- 
tering Officinal and other Medicines. The wnole adapteil to Physicians and Pharuiaoeut- 
ists. Third edition, thoroughly revised, with numerous additions, by John M. Maisch, 
Phar. D., Professor of Materia JNIedioa and Botany in the Pliihulelphia College of Pharmacy. 
In one octavo volume of 775 pajre.s, with 38 illustrations. Cloth, $4.50 ; leather, $5.50. 



12 Lea Brothers & Co.'s Publications — Mat. Med., Therap. 



STILLB, A., M.n.,LL.n., & MAISCS, J. M.,Phar.n., 



Prof essor Emeritus of the Theory and Prac- 
tice of Medicine and of Clinical Medicine 
in the University of Pennsylvania. 



Prof, of Mat. Med. and Botany in Phila, 
College of Pharmacy, Sec'y to the Ameri- 
can Pharmaceutical Association. 



The National Dispensatory. 

CONTAINING THE NATURAL HISTORY, CHEMISTRY, PHARMACY, ACTIONS AND USES OF 

MEDICINES, INCLUDING THOSE RECOGNIZED IN THE PHARMACOPCEIAS OF THE 

UNITED STATES, GREAT BRITAIN AND GERMANY, WITH NUMEROUS 

REFERENCES TO THE FRENCH CODEX. 

Fourth edition revised, and covering the new British Pharmacopoeia. In one mag- 
nificent imperial octavo volume of 1794 pages, with 311 elaborate engravings. Price 
in cloth, $7.25 ; leather, raised bands, $8.00. *^*This work will be furnished with Patent 
Beady Reference Thumb-letter Index for $1.00 in addition to the price in any style of binding. 

In this new edition of The National Dispensatory, all important changes in the 
recent British Pharmacopoeia have been incorporated throughout the volume, while in 
the Addenda will be found, grouped in a convenient section of 24 pages, all therapeutical 
novelties which have been established in professional favor since the publication of the 
third edition two years ago. Since its first publication. The National Dispensatory 
has been the most accurate work of its kind, and in this edition, as always before, it may 
be said to be the representative of the most recent state of American, English, German 
and French Pharmacology, Therapeutics and Materia Medica. 



It is with much pleasure that the fourth edition 
of this magnificent work is received. The authors 
and publishers have reason to feel proud of this, 
the most comprehensive, elaborate and accurate 
work of the kind ever printed in this country. It 
is no wonder that it has become the standard au- 
thority for both the medical and pharmaceutical 
profession, and that four editions have been re- 
quired to supply the constant and increasing 
demand since its first appearance in 1879. The 
entire field has been gone over and the various 
articles revised in accordance with the latest 
developments regarding the attributes and thera- 
peutical action of drugs. The remedies of recent 



discovery have received due attention. — Kansas 
City Medical Index, Nov. 1887. 

We think it a matter for congratulation that the 
profession of medicine and that of pharmacy have 
shown such appreciation of this great work as to call 
for four editions within the comparatively brief 
period of eight years. The matters with which it 
deals are of so practical a nature that neither the 
physician nor the pharmacist can do without the 
latest text-books on them, especially those that are 
so accurate and comprehensive as this one. The 
book is in every way creditable both to the authors 
and to the publishers.— iVeu; York Medical Journal^ 
May 21, 1887. 



FABQVHABSON, BOBEBT, M. !>., F. B. C. B., LL. JD., 

Lecturer on Materia Medica at St. Mary^s Hospital Medical School, London. 

A Guide to Therapeutics and Materia Medica. New (fourth) American, 
from the fourth English edition. Enlarged and adapted to the U. S. Pharmacopoeia. By 
Frank Woodbury, M. D., Professor of Materia Medica and Therapeutics and Clinical 
Medicine in the Medico-Chirurgical College of Philadelphia. In one handsome 12mo. 
volume of 581 pages. Cloth, |2.50. Just ready. 



It may correctly be regarded as the most modern 
work of its kind. It is concise, yet complete. 
Containing an account of all remedies that have 
a place in the British and United States Pharma- 
copceias, as well as considering all non-oflBcial but 
important new drugs, it becomes in fact r miniature 
dispensatory. — Pacific Medical Journal, June, 18»9. 

Farquharson's Guide is becoming more widely 
known, and doubtless will be more acceptable with 
each revision, as it has in this. It is just the book 



the young doctor will consult with profit in very 
many of his daily emergencies, ana to all such, 
yes, and to many of the grave and reverend 
seniors we commend it most heartily. — North 
Carolina Medical Journal, July, 1889. 

We have in the preceding issues of this journal 
had occasion to call attention to the previous edi- 
tions of this excellent work, which in its present 
form retains all the special features of its former 
editions.— Southern Practitioner, July, 1889. 



BBES, BOBBBT T., M. D., 

Jackson Professor of Clinical Medicine in Harvard University, Medical Department. 

A Text-Book of Therapeutics and Materia Medica. Intended for the 
Use of Students and Practitioners. Octavo, 544 pages. Cloth, $3.50 ; leather, $4.50. 

cine. Such they can find in the present author. 
All the newest drugs of promise are treated of. 
The clinical index at the end will be found very 
useful. We heartily commend the book and con- 



The treatise will be found to be concise and 
practical, bringing the subject down to the latest 
developments of therapeutics and pharmacology. 
The student and practitioner will find the book a 
valuable one for reference and study, the former 
being facilitated by a full and excellent index. — 
St. Louis Medical and Surgical Journal, Jan. 1888. 

The present work seems destined to take a prom- 
inent place as a text-book on the subjects of which 

treats. It possesses all the essentials which we 
expect in a book of its kind, such as conciseness, 
clearness, a judicious classification, and a reason- 
able degree of dogmatism. The style deserves 
the highest commendation for its dignity and 
purity of diction. The student and young practi- 
tioner need a safe guide in this branch of medi- 



gratulate the author on having produced so good 
a one.— iV. F. Medical Journal, Feb. 18, 1888. 

Dr. Edes' book represents better than any older 
book the practical therapeutics of the present 
day. The book is a thoroughly practical one. The 
classification of remedies has reference to their 
therapeutic action, and such a classification will 
always meet the approval of the student. The rela- 
tive importance of different remedies is indicated 
by the space devoted to each, and by the use of 
larger type in the titles of the more important 
&Tticle3.— Pharmaceutical Era, Jan. 1888. 



Lea Brothers & Co.'s Publications — Pathol., Histol, 



13 



BAYNB, JOSBBH F., M. ID., F. It. C. jP., 

Member of the Pathological Society, Senior Assistant Physician and Lecturer on Pathological Anat- 
omy, St. Thomas' Hospital, London. 

A Manual of General Pathology. Designed as an Introduction to the Prac- 
tice of Medicine. Octavo of 524 pages, with 152 illus. and a colored x)late. Cloth, $3.50. 



Knowing, as a teacher and examiner, the exact 
needs of medical students, the author has in the 
work before us prepared for their especial use 
what we do not hesitate to say is the best introduc- 
tion to general pathology that we have yet ex- 
amined. A departure which our author has 
taken is the greater attention paid to the causa- 
tion of disease, and more especially to the etiologi- 



cal factors in those diseases now with reasonable 
certainty ascribed to pathogenetic microbes. In 
this department he has been very full and explicit, 
not only in a descriptive manner, but in the tech- 
nique of investigation. The Appendix, giving 
methods of reseai ch, is alone worth the price of the 
book, several times over, to every student of 
pathology.— <S'<. Louis Med. and Surg, Jour.,J&n.'80. 



SFKJ!f, NICHOLAS, M.D., Fh.I>., 

Professor of Principles of Surgery and Surgical Pathology in Rush Medical College, Chicago. 

Surgical Bacteriology. In one handsome octavo of 259 pages, with 13 plates, 
of which 9 are colored. Cloth, $1.75. Just ready. 
The author in this excellent monograph has very will make a mistake in not supplying themselves 
■ ■ with this work. The facts in regard to this im- 

portant subject are made so plain and considered 
in such a satisfactory manner that we can but 
regard it as one of the most important contributions 
to the medical literature of the ye&T.—Southern 



concisely yet fully and comprehensively gone over 
the field, and placed before the medical public a 
most valuable treatise on the subject. We know 
of no one better qualified for the task he has 
assumed, and doubt if anyone could have dis- 
charged the duty so well. Those who would not 
be behind the wonderful developments of the day 



Practitioner^ June 1, 1889. 



COATS, JOSBFM, M. D., F. F. F. S., 

Pathologist to the Glasgow Western Infirmary. 

A Treatise on Pathology. In one very handsome octavo volume of 829 pages, 
with 339 beautiful illustrations. Cloth, |5.50 ; leather, $6.50. 
The work before us treats the subject of Path- 



ology more extensively than it is usually treated 
in similar works. Medical students as well as 
physicians, who desire a work for study or refer- 
ence, that treats the subjects in the various de- 
partments in a very thorough manner, but without 
prolixity, will certainly give this one the prefer- 
ence to aa^y with which we are acquainted. It sets 



forth the most recent discoveries, exhibits, in an 
interesting manner, the changes from a normal 
condition effected in structures by disease, and 
points out the characteristics of various morbid 
agencies, so that they can be easily recognized. Bu t, 
not limited to morbid anatomy,it explains fully how 
the functions of organs are disturbed by abnormal 
conditions. — Cincinnati Medical News, Oct. 1883. 



GBBBN, T. JBEBWBT, M. !>., 

Lecturer on Pathology and Morbid Anatomy at Charing-Cross Hospital Medical School, London. 

Pathology and Morbid Anatomy. New (sixth) American from the seventh 
revised English edition. In one octavo vol. of 539 pp., with 167 engravings. Cloth, §2.75. 
Just ready. 

WOOnHBAB, G. SIMS, M. JD., F. B. C. F. B., 

Demonstrator of Pathology in the University of Edinburgh. 
Practical Pathology. A Manual for Students and Practitioners. In one beau- 
tiful octavo volume of 497 pages, with 136 exquisitely colored illustrations. Cloth, $6.00. 

It forms a real guide for the student and practi- themselves with this manual. The numerous 
tioner who is thoroughly in earnest in his en- drawings are not fancied pictures, or merely 
deavor to see for himself and do for himself. To schematic diagrams, but they represent faithfully 
the laboratory student it will be a helpful com- the actual images seen under the microscope, 
panion, and all those who may wish to familiarize The author merits all praise for having produced 
themselves with modern methods of examining a valuable work. — Medical Record, May 31, 1SS4. 
morbid tissues are strongly urged to provide 



SCHAFBB, BDWABn A., F. B. S., 

Assistant Professor of Physiology in University College, London* 

The Essentials of Histology. In one octavo volume of 246 pages, with 
281 illustrations. Cloth, $2.25. 

This admirable work was greatly needed. It 
has been written with the object of supplying 
the student with directions for the microscopical 
examination of the tissues, which are given in a 
clear and understandable way. Although espe- 
cially adapted for laboratory work, at the same 



time it is intended to serve as an elementary 
text-book of histology, comprising all the essen- 
tial facts of the science. The author has recom- 
mended only those methods upon which long ex- 
perience has proved that full dependence can b« 
placed. — The Physician arid Surgeon, July, 1887. 



KLBIN, B., M. n., F. B. S., 

Joint Leettirer on Oeneral Anat. and Phys. in the Med. School of St. Bartholommo's Hasp., London, 
Elements of Histology. Fourth edition. In one 12mo. volume of 376 pages, 
with 194 illus. Limp cloth, $1.75. JuM ready. See Students* Series of Manwds, page 4. 

Considered with regard to its contents, it can 
only be looked on as a large anji comprehensive 
volume. New and oritciual illustrations have boon 
added, with the help of which the structure of each 
tissue becomes clear to the reader. .\ copious 



index atTords a ready reference to the histology of 
every tissue and organ, and presentv>», at the same 
time, a complete glossary of thesoieutifio t^rms.— 
Provincial Medical Jounuil, Maj' 1, 1SS9. 



FBFFBB, A. J., M. B., M. S., F. B. C. S., 

Sui-gcon and Lecturer at St. Mary's Hospital-^ London, 
Surgical Pathology. In one pocket-size 12iuo. volume of 511 i>3^e8, with SI 
illustrations. Limp cloth, red edges, $2.00. See St udents^ Series of ^fa n luds, page 4. 

Its form is practical, its language is clear, and I in it nothing that is unneoes^arv. The list o( 
the Information set forth is well-arranged, well- subjects covers the whole range of sr.rgery. — yew 
indeised and well-illustrated. The student will t\ud | York Medical Journal^ May 31, 1SS4. 



14 



Lea Brothers & Co.'s Publications — Practice of Med. 



FLIJS^T, AUSTIN, M. D., LL. ID. 

Prof, of the Principles and Practice of Med. and of Clin. Med. in Bellevue Hospital Medical Ck)llege, N. F. 

A Treatise on the Principles and Practice of Medicine. Designed for 
tiie use of Students and Practitioners of Medicine. New (sixth) edition, thoroughly re- 
vised and rewritten by the Author, assisted by William H. Welch, M. D., Professor of 
Pathology, Johns Hopkins University, Baltimore, and Austin Flint, Jr., M. D., LL. D., 
Professor of Physiology, Bellevue Hospital Medical College, N. Y. In one very handsome 
octavo volume of 1160 pages, with illustrations. Cloth, $5.50 ; leather, $6.50. 



A new edition of a work of such established rep- 
utation as Flint's Medicine needs but few words to 
commend it to notice. It may in truth be said to 
embody the fruit of his labors in clinical medicine, 
ripened by the experience of a long life devoted to 
its pursuit. America may well be proud of having 
produced a man whose indefatigable industry and 
gifts of genius have done so much to advance med- 
icine; and all English-reading students must be 
frateful for the work which he nas left behind him. 
t has few equals, either in point of literary excel- 
lence, or of scientific learning, and no one can 
study its pages without being struck by the lu- 
cidity and accuracy which characterize them. It 
is qualities such as these which render it so valu- 
able for its purpose, and give it a foremost place 
among the text-books of this generation. — The 
London Lancet, March 12, 1887. 

No text-book on the principles and practice of 
medicine has ever met in this country with such 



general approval by medical students and practi- 
tioners as the work of Professor Flint. In all the 
medical colleges of the United States it is the fa- 
vorite work upon Practice; and, as we have stated 
before in alluding to it, there is no other medical 
work that can be so generally found in the libra- 
ries of physicians. In every state and territory 
of this vast country the book that will be most likely 
to be found in the office of a medical man, whether 
in city, town, village, or at some cross-roads, is 
Flint's Practice. We make this statement to a 
considerable extent from personal observation, and 
it is the testimony also of others. An examina- 
tion shows that very considerable changes have 
been made in the sixth edition. The work may un- 
doubtedly be regarded as fairly representing the 
present state of the science of medicine, and as 
reflecting the views of those who exemplify in 
their practice the present stage of progress of med- 
ical 9.xt.— Cincinnati Medical News, Oct. 1886. 



SAItTSMOMNB, SBWBY, M. 2>., LL. L>., 

Lately Professor of Hygiene in the University of Pennsylvania. 

Essentials of the Principles and Practice of Medicine. A Handbook 
for Students and Practitioners. Fifth edition, thoroughly revised and rewritten. In one 
royal 12mo. volume of 669 pages, with 144 illustrations. Cloth, $2.75 ; half bound, $3.00. 



Within the compass of 600 pages it treats of the 
history of medicine, general pathology, general 
symptomatology, and physical diagnosis (including 
laryngoscope, ophthalmoscope, etc.), general ther- 
apeutics, nosology, and special pathology and prac- 
tice. There is a wonderful amount of information 
contained in this work, and \i is one of the best 
of its kind that we have seen. — Glasgow Medical 
Journal, Nov. 1882. 

An indispensable book. No work ever exhibited 
a better average of actual practical treatment than 



this one; and probably not one writer in our day 
had a better opportunity than Dr. Hartshorne for 
condensing all the views of eminent practitioners 
into a 12mo. The numerous illustrations will be 
very useful to students especially. These essen- 
tials, as the name suggests, are not intended to 
supersede the text-books of Flint and Bartholow, 
but they are the most valuable in affording the 
means to see at a glance the whole literature of any 
disease, and the most valuable treatment. — Chicago 
Medical Journal and Examiner, April, 1882. 



BBISTOWE, JOSW SYBM, M. !>., jP. B. C. JP., 

Physician and Joint Lecturer on Medicine at St. Thomas^ Hospital, London. 

A Treatise on the Practice of Medicine. Second American edition, revised 
by the Author. Edited, with additions, by James H. Hutchinson, M.D., physician to the 
Pennsylvania Hospital. In one handsome octavo volume of 1085 pages, with illustrations. 
Cloth, $5.00; leather, $6.00. 



The book is a model of conciseness, and com- 
bines, as successfully as one could conceive it to 
be possible, an encyclopsedic character with the 
smallest dimensions. It differs from other admi- 
rable text-books in the completeness with which 
it covers the whole field of medicine. — Michigan 
Medical News, May 10, 1880. 

His accuracy in the portraiture of disease, his 
care in stating subtle points of diagnosis, and the 
faithfully given pathology of abnormal processes 
have seldom been surpassed. He embraces many 
diseases not usually considered to belong to theory 



and practice, as skin diseases, syphilis and insan- 
ity, but they will not be objected to by readers, as 
he has studied them conscientiously, and drawn 
from the life. — Medical and Surgical Reporter, De- 
cember 20, 1879. 

The reader will find every conceivable subject 
connected with the practice of medicine ably pre- 
sented, in a style at once clear, interesting and 
concise. The additions made by Dr. Hutchinson 
are appropriate and practical, and greatly add to 
its usefulness to American readers. — Buffalo Med- 
ical and Surgical Journal, March, 1880. 



WATSOW, Sin TSEOMAS, M. n., 

Late Physician in Ordinary to the Queen. 

Lectures on the Principles and Practice of Physic. A new American 
from the fifth English edition. Edited, with additions, and 190 illustrations, by Henry 
Hartshobne, a. M., M. D., late Professor of Hygiene in the University of Pennsylvania. 
In two large octavo volumes of 1840 pages. Cloth, $9,00 ; leather, $11.00. 



LECTURES ON THE STUDY OF FEVER. By 
A. Hudson, M. D., M. R. I. A. In one octavo 
volume of 308 pages. Cloth, $2.50, 

A TREATISE ON FEVER. By Robert D. Lyons, 
K. C. C. In one 8vo. vol. of 354 pp. Cloth, $2.26. 



LA ROCHE ON YELLOW FEVER, considered in 
its Historical, Pathological, Etiological and 
Therapeutical Relations, In two large and hand- 
some octavo volumes of 1468 pp. Oloth. $7.00. 



Lea Brothers & Co.'s Publications — System of Med. 



15 



For Sale hy Subscription Only, 



A System of Practical Medicine. 

BY AMERICAN AUTHORS. 

Edited by WILLIAM PEPPER, M. D., LL. D., 

PROVOST AND PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE AND OF 
CUNICAI. MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA, 

Assisted by Louis Starr, M. D., Clinical Professor of the Diseases of Children in the 
Hospital of the University of Pennsylvania. 

The complete work, in five volumes, containing 5573 pages, with 198 illustrations, is now ready. 
Price per volume, cloth, $5; leather, $6 ; half Russia, raised bands and open back, $7. 



In this great work American medicine is for the first time reflected by its worthiest 
teachers, and presented in the fall development of the practical utility which is its pre- 
eminent characteristic. The most able men — from the East and the West, from the 
North and the South, from all the prominent centres of education, and from all the 
hospitals which afford special opportunities for study and practice — have united in 
generous rivalry to bring together this vast aggregate of specialized experience. 

The distinguished editor has so apportioned the work that to each author has been 
assigned the subject which he is peculiarly fitted to discuss, and in which his views 
will be accepted as the latest expression of scientific and practical knowledge. The 
practitioner will therefore find these volumes a complete, authoritative and unfailing work 
of reference, to which he may at all times turn with full certainty of finding what he needs 
in its most recent aspect, whether he seeks information on the general principles of medi- 
cine, or minute guidance in the treatment of special disease. So wide is the scope of the 
work that, with the exception of midwifery and matters strictly surgical, it embraces the 
whole domain of medicine, including the departments for which the physician is accustomed 
to rely on special treatises, such as diseases of women and children, of the genito-urinary 
organs, of the skin, of the nerves, hygiene and sanitary science, and medical ophthalmology 
and otology. Moreover, authors have inserted the formulas which they have found most 
efficient in the treatment of the various affections. It may thus be truly regarded as a 
Complete Library of Practical Medicine, and the general practitioner possessing it 
may feel secure that he will require little else in the daily round of professional duties. 

In spite of every effort to condense the vast amount of practical information fur- 
nished, it has been impossible to present it in less than 5 large octavo volumes, containing 
about 5600 beautifully printed pages, and embodying the matter of about 15 ordinary 
octavos. Illustrations are introduced wherever requisite to elucidate the text. 

A detailed prospectus will be sent to any address on application to the publishers. 



These two volumes bring this admirable work 
to a close, and fully sustain the high standard 
reached by the earlier volumes; we have only 
therefore to echo the eulogium pronounced upon 
them. We would warmly congratulate the editor 
and his collaborators at the conclusion of their 
laborious task on the admirable manner in which, 
from first to last, they have performed their several 
duties. They have succeeded in producing a 
work which will long remain a standard work of 
reference, to which practitioners will look for 

fuidance, and authors will resort for facts, 
'rom a literary point of view, the work is without 
any serious blemish, and in respect of production, 
it has the beautiful finish that Americans always 

five their works. — Edinburgh Medical Journal, Jan. 
887. 

♦ * Thegreatestdistinctively American work on 
the practice of medicine, and, indeed, the super- 
lative adjectiv« would not be inappropriate were 
even all other productions placed in comparison. 
An examination of the five volumes is sufficient 
to convince one of the magnitude of the enter- 

Krise, and of the success which has attended its 
ilfilmont.— r/ie Maiical Age, July 20, ISSO. 
This huge volume forms a fitting close to the 

f;reat system of medicine which in* so short a time 
las won so high a plat'.e in medical literature, and 
has done such credit to the urofessiou in tl\is 
country. Among the twentv-tliree contributors 
are the names of the leading' neurologists in 
America, and most of the work in the volume is of 
the highest order. — Boston j[Iedical and iSurgicai 
Journal, July 21, 1887. 

We consider it one of the fijrandest works on 
Practical Medicine in the English language. It is 
a work of which the profession of this country can 
feel proud. Written exclusively by Ame'ric^vn 



physicians who are acquainted with all the varie- 
ties of climate in the United States, the character 
of the soil, the manners and customs of the peo- 
ple, etc., it is peculiarly adapted to the want^ 
of American practitioners of medicine, and it 
seems to us that every one of them would desire 
to have it. It has been truly called a "Complete 
Library of Practical Medicine," and the general 
practitioner will require little else in his, round 
of professional duties. — Cincinnati Medical' iN'etrs, 
March, 1886. 

Each of the volumes is provided with a most 
copious index, and the work altogether promises 
to be one which will add much to the medical 
literature of the present centurv, and reflect great 
credit upon the scholarship ana practical acumen 
of its authors.— TTie London Lancet, Oct. a, 1885. 

The feeling of proud satisfaction with which the 
American profession sees this, its representative 
system of practical medicine issued to the medi- 
cal world, IS fully justified by the character of the 
work. The entire ca.-^te of the system is iu keeD- 
iog with the best thoughts of the leaders and fcu- 
lowers of our home scho^tl of medicine, and the 
combination of the scientific study of disease and 
the onvctical application of exact and experimen- 
tal kuowledgtj to the treatment of human mal- 
adies, makes every one of us share iu the pride 
that has welcomed Pr. ^op^>or's lalH->rs. Sheared 
of the prolixity that wearies tlie readers of the 
Germ.an school, the articles clean those same 
fields for all that is valu.>»ble. tt is the outoome 
of .\merican brains, and is marked tlirougheut 
by much of the sturdy indcpeudeuce of thoucht 
and originality that is a national oharaot^eristic. 
Yet nowhere "is there lack of study of the mo«l 
advanced views of the dAV.—Xorth Oarolvta Maii- 
cal Journal, Sept. ISSiv. 



16 Lea Brothers & Co.'s Publications — Clinical Med., etc. 

FOTSBRGILL9 J. M.^ M. 2>., Edin., M. B. C. -P., Land., 

Physician to the City of London Hospital for Diseases of the Chest. 

The Practitioner's Handbook of Treatment ; Or, The Principles of Thera- 
peutics. New (third) edition. In one 8vo. vol. of 661 pages. Cloth, $3.75 ; leather, $4.75. 



To have a description of the normal physiologi- 
cal processes of an organ and of the methods of 
treatment of its morbid conditions brought 
together in a single chapter, and the relations 
between the two clearly stated, cannot fail to prove 
a great convenience to many thoughtful but busy 
physicians. The practical value of the volume is 
greatly increased by the introduction of many 
prescriptions. That the profession appreciates 
that the author has undertaken an important work 
and has accomplished it is shown by the demand 
for this third edition.— iV. Y. Med. Jour., June 11 '87. 



This is a' wonderful book. If there be such a 
thing as "medicine made easy," this is the work to 
accomplish this result. — Va. Med. Month., June,'87. 

It is an excellent, practical work on therapeutics, 
well arranged and clearly expressed, useful to the 
student and young practitioner, perhaps even to 
the old. — Dublin Journal of Medical Science, March 
1888. 

We do not know a more readable, practical and 
useful work on the treatment of disease than the 
one we have now before us.— Pacific Medical and 
Surgical Journal, October, 1887. 



VATTGSAW, VICTOB €,, Ph. I>., M. JD., 

Prof, of Phys. and Path. Chem. and Assoc. Prof, of Therop. and Mat. Med. in the Univ. of Mich. 

and :^OVY, FBJE DUMICK G., M. D. 

Instructor in Hygiene and Phys. Chem. in the Univ. of Mich. 

Ptomaines and Leueomaines, or Putrefactive and Physiological 
Alkaloids. In one handsome 12mo. volume of 311 pages. Just ready. Cloth, $1.75. 

This book is what has been wanted for some 
years by the medical profession. The subject of 



ptomaines and leueomaines, so far as their disease' 
producing relations are concerned, has been under 
8I)ecial study scarcely more than a decade, but 
within that period facts have been discovered 
upon which theories of permanent standing have 
been built, until now the practitioner is far be- 
hind the times if he does not appreciate the 
importance of ptomaines. This is the first attempt 
made to collect into book form the results of 



observers and experimenters on micro-organisms, 
and to trace the relationship of cause and effect 
of the putrefaeative alkaloids. We congratulate 
the authors upon the successful presentation of 
the current views on the subject in such manner 
as to make them easily comprehensible, while to 
the practitioner, after he has carefully read the 
book, it will serve, also, as a frequent reference 
work, because of the technical information it gives. 
Va. Medical Monthly, Sept. 1888. 



BBYNOLDS, J. HUSSELL, M. J>., 

Professor of the Principles and Practice of Medicine in University College, London. 

A System of Medicine. With notes and additions by Henry Hartshorne, 
A. M., M. D., late Professor of Hygiene in the University of Pennsylvania. In three large 
and handsome octavo volumes, containing 3056 double-columned pages, with 317 illustra- 
tions. Price per volume, cloth, $5.00 ; sheep, $6.00 ; very handsome half Kussia, raised bands, 
$6.50. Per set, cloth, $15; leather, $18. Sold only by subscription. 

8TILLB, ALFBBD, M. D., LL. !>., 

Professor Emeritus of the Theory and Practice of Med. and of Clinical Med. in the Univ. of Penna. 
Cholera: Its Origin, History, Causation, Symptoms, Lesions, Prevention and Treat- 
ment. In one handsome 12mo. volume of 163 pages, with a chart. Cloth, $1.25. 

FUSXATSON, JAMBS, M. D., Editor, 

Physician and Lecturer on Clinical Medicine in the Glasgow Western Infirmary, etc. 

Clinical Manual for the Study of Medical Cases. With Chapters 
by Prof. Gairdner on the Physiognomy of Disease; Prof. Stephenson on Diseases of 
the Female Organs; Dr. Kobertson on Insanity; Dr. Gemmell on Physical Diagnosis ; 
Dr. Coats on Laryngoscopy and Post-Mortem Examinations, and by the Editor on Case- 
taking, Family History and Symptoms of Disorder in the Various Systems. New edition. 
In one 12mo. volume of 682 pages, with 158 illustrations. Cloth, $2.50. 

and a study of means to the end which cannot 



This manual Is one of the most complete and 
perfect of its kind. It goes thoroughly into the 

?uestion of diagnosis from every possible point, 
t must lead to a thoroughness of observation, an 
examination in detail of every scientific appliance. 



fail in laying an excellent foundation for the 
student for future success as an able diagnostician. 
—Medical Record, August 13, 1887. 



FENWICK, SAMUEL, M. 2>., 

Assistant Physician to the London Hospital. 

The Student's Guide to Medical Diagnosis. From the third revised and 
enlarged English edition. In one very handsome royal 12mo. volume of 328 pages, with 
87 illustrations on wood. Cloth, $2.25. 

HABBBSMOJSr, S. O., M. I)., 

Senior Physician to and late Lect. on Principles and Practice of Med. at Ouy^s Hospital, London, 

On the Diseases of the Abdomen ; Comprising those of the Stomach, and 
other parts of the Alimentary Canal, (Esophagus, Caecum, Intestines and Peritoneum. Second 
American from third enlarged and revised English edition. In one handsome octavo 
volume of 554 pages, with illustrations. Cloth, $3.50. 

TAinnSB, THOMAS MAWKES, ^Tjy. 

A Manual of Clinical Medicine and Physical Diagnosis. Third American 
from the second London edition. Bevised and enlarged by Telbhry Fox, M. D. 
In one small 12mo. volume of 362 pages, with illustrations. Cloth, $1.50. 



Lea Brothers & Co.'s Publications — Hygiene, Electr., Pract. 17 



BABTELOLOW, BOBBBTS, A. M., M, JD., LL. !>., 

Prof, of Materia Medica and General Therapeutics in the Jefferson Med. Coll. of Phila., etc. 
Medical Electricity. A Practical Treatise on the Applications of Electricity 
to Medicine and Surgery. New (third) edition. In one very handsome octavo volume of 
308 pages, with 110 illustrations. Cloth, $2.50. 

The fact that this work has reached its third edi- 
tion in six years, and that it has been kept fully 
abreast with the increasing use and knowledge of 
electricity.demonstrates its claim to be considered 
a practical treatise of tried yalue to the profession. 
The matter added to the present edition embraces 
the most recent advances in electrical treatment. 
The illustrations are abundant and clear, and the 
work constitutes a full, clear and concise manual 
well adapted to the needs of both student and 
practitioner.— The Medical News, May 14, 1887. 

This "practical treatise on the applications of 
electricity to medicine and surgery" has grown to 
be so important a work that every practitioner 



should read it, especially when it is recalled what 
possibilities lie in the path of the further study of 
the therapeutics of electricity. Dr. Bartholow has 
here presented the profession with a concise work 
that, beginning with elementary descriptions and 
principles, gradually grows, page by page, into a 
magnificently practical treatise, describing opera- 
tions in detail, and giving records of successes 
that prove electricity to be marvellous as a curative 
agent in many forms of disease. The doctor can- 
not now do better than to possess himself of Dr. 
Bartholow's treatise, just as it is. — Virginia Medi- 
cal Monthly, June, 1887. 



BICMABDSOW, B. W., M.B., LB. D., B.B.S., 

Fellow of the Royal College of Physicians, London. 

Preventive Medicine. In one octavo volume of 729 pages. Cloth, $4 ; leather, 
$5 ; very handsome half Eussia, raised bands, $5.50. 

Dr. Richardson has succeeded in producing a 
work which is elevated in conception, comprehen 



sive in scope, scientific in character, systematic in 
arrangement, and which is written in a clear, con- 
cise and pleasant manner. He evinces the happy 
faculty of extracting the pith of what is known on 
the subject, and of presenting it in a most simple. 
Intelligent and practical form. There is perhaps 
no similar work written for the general public 
that contains suchacomplete*reliable and instruc- 
tive collection of data upon the diseases common 
to the race, their origins, causes, and the measures 
for their prevention. The descriptions of diseases 
are clear, chaste and scholarly ; the discussion of 



the question of disease is comprehensive, masterly 
and fully abreast with the latest and best knowl- 
edge on the subject, and the preventive measures 
advised are accurate, explicit and reliable.— TTie 
American Journal of the Medical Sciences, April, 1884. 

This is a book that will surely find a place on the 
table of every progressive physician. To the medi- 
cal profession, whose duty is quite as much to 
prevent as to cure disease the book will be a boon. 
— Boston Medical and Surgical Journal, March 6, '84. 

The treatise contains a vast amount of solid, val- 
uable hygienic infoTmsition.— Medical and Surgical 
Reporter, Feb. 23, 1884. 



THB TBAB-BOOK OF TBBATMBNT FOB 1889. 

A Comprehensive and Critical Review for Practitioners of Medi- 
cine. In one 12mo. volume of 349 pages, bound in limp cloth, $1.25. Just ready. 

^*.5{. For special commutations with periodicals see page 2. 

THB TBAB-BOOK OF TBBATMBNT FOB 1887. 

Similar to above. 12mo., 341 pages. Limp cloth, $1.25. 



this is one of the most valuable books for its 

Erice which is published in this or any coun- 
:y. It contains a summary of the changes in 
medical practice, the new remedies introduced, 
and the experience with them and with others 
which have been longer in use, during the year 
1887, made up from the reading and observation 
of a number of very capable men. The classifica- 
tion is according to diseases, so that one who con- 



sults these pages can obtain in a few minutes an 
excellent idea of the present status of therapeu- 
tics in regard to any given ailment. The book 
also has a good index, by means of which the 
reader may ascertain the different diseases for 
which any particular drug has been used during 
the year past.— iV/edicai mid Surgical Reporter, 
April 14, 1888. 



TBTB TBAB'BOOK OF TBBATMBNT FOB 1886. 

Similar to that of 1887 above. 12mo., 320 pages. Limp cloth, $1.25. 

scb:bbibbb, bb. josbbh. 

A Manual of Treatment by Massage and Methodical Muscle Ex- 
ercise. Translated by Walter Mendelson, M. D., of New York. In one handsome 
octavo volume of 274 pages, with 117 fine engravings. Just ready. Cloth, $2.75. 

This is a work abounding in common sense, a 
book that sweeps away a great deal of nonsense 
by which a simple matter has been made obscure, 
a volume that ought to be read by every one inter- 



ested in modern therapeutics. The work gives 
admirable directions for the employment of mas- 
sage, and capital descriptions of methodical exer- 



cise, after which there is a detailed account of the 
results of treatment of ditferent diseases by these 
methods. A full bibliography adds to the value of 
the volume, which can oe recommended as one of 
the best on the subjects with which it deals.— 
Edinburgh Medical Journal, April, 16SS. 



8TURGES' INTRODUCTION TO THE STUDY 
OF CLINICAL MEDICINE. Being a Guide to 
the Investigation of Disease. In one handsome 
12mo. volume of V2,7 pages. Cloth, §1.25. 

DAVIS' CLINICAL IvKCTURES ON VARIOUS 
IMPORTANT DISEASES. By N. S. Davih, 
M. D. Edited by Fuank H. Davis, M.D. Second 
edition. 12mo. 287 pages. Cloth, $1.75. 

TODD'S CLINICAL LECTURES ON CERTAIN 
ACUTE DISEASES. In one octavo volume of 
820 pages. Cloth, $2.50. 



PAVY'S TREATISE ON THE FUNCTION OF DI- 
GESTION; its Disorders and their Treatment. 
From the second London edition. In one octavo 
volume of 238 pages. Cloth. S2.iX\ 

BARLOW'S MANUAL OF THE PR.VCTICE OF 
MEDICINE. With additions bv D. F. Coxdik, 
M. D. 1 vol. Svo.. pp. 6(V3. Cloth". $--'.vV\ 

CHAMBERS' MANUAL OF DIET AND REGIMEN 
IN HEALTH AND SICKNESS. li\ one hand- 
some octavo volume of 8i>2 pp. Clotl'., S2.7v^ 

HOLLAND'S MEDICAL NOTES AND REFLEC- 
TIONS. 1 vol. Svo., pp. 493. Cloth, 83.50. 



18 Lea Brothers & Co.'s Publications — Throat, Liung-s, Heart. 



FLINT, AVSTIW, M. !>., LL. D., 

Professor of the Principles and Practice of Medicine in Bellemie Hospital Medical College, N. 7. 

A. Manual of Auscultation and Percussion ; Of the Physical Diagnosis of 
jDiseases of the Lungs and Heart, and of Thoracic Aneurism. Fourth edition. In one 
handsome royal 12mo. volume of 278 pages, with 14 illustrations. Cloth, $1.75. 



The original work done by Dr. Flint in the devel- 
opment of the art of physical diagnosis will always 
make this manual an authority on this subject. 
Among all the works issued on this topic during 
the last few years, none exceeds this one in sim- 
plicity and completeness. The fact that it has 



passed through four editions attests its popularity. 
There is a tendency among physical diagnosti- 
cians to make altogether too many varieties of 
morbid chest sounds, and especially of rales. The 
conciseness of Dr. Flint's Manual is one of its chief 
advantages — Medical Record, June 16, 1888. 



B 7 THE SAME A UTHOR. 



A Practical Treatise on the Physical Exploration of the Chest and 
the Diagnosis of Diseases Affecting the Respiratory Organs. Second and 
revised edition. In one handsome octavo volume of 591 pages. Cloth, $4.50. 

Phthisis: Its Morbid Anatomy, Etiology, Symptomatic Events and 
Complications, Fatality and Prognosis, Treatment and Physical Diag- 
nosis ; In a series of Clinical Studies. In one octavo volume of 442 pages. Cloth, $3.50. 

A Practical Treatise on the Diagnosis, Pathology and Treatment of 
Diseases of the Heart. Second revised and enlarged edition. In one octavo volume 
of 550 pages, with a plate. Cloth, $4. 

Essays on Conservative Medicine and Kindred Topics. In one very hand- 
some royal 12mo. volume of 210 pages. Cloth, $1.38. 



BMOWNJE, LJENNOX, F. B. C. S., JE., 

Senior Physician to the Central London Throat and Ear Hospital. 

A Practical Guide to Diseases of the Throat and Nose, including 
Associated Affections of the Ear. With 120 illustrations in color, and 200 en- 
gravings on wood designed and executed by the Author. New (second) and enlarged 
edition. In one imperial octavo volume of 628 pages. Cloth, $6. 



Mr. Browne's book can be recommended to 
students and still more to practitioners as a clear, 
sound and practical guide to the diagnosis and 
treatment of diseases of the throat. His experi- 
ence is not only large, but ripe, and he gives his 
readers the full benefit of it. A particularly praise- 



worthy feature is that from beginning to end Mr. 
Browne, whilst giving due prominence to local 
measures, never fails to insist on the necessity of 
supplementing these by proper constitutional 
treatment. — London Medical Recorder, May, 1888. 



SEILBB, CABL, M. JD., 

Lecturer on Laryngoscopy in the University of Pennsylvania. 

A Handbook of Diagnosis and Treatment of Diseases of the Throat, 
Nose and Naso-Pharynx. New (third) edition. In one handsome royal 12mo. 
volume of 373 pages, with 101 illustrations and 2 colored plates. Cloth, $2.25. Just ready. 
Few medical writers surpass this author in | of topics and methods. The book deserves a large 
ability to make his meaning perfectly clear In a sale, especially among general practitioners— C/ii- 
few words, and in discrimination in selection, both | cago Medical Journal and Examiner, April, 1889. 



GBOSS, S. D., M.n., LL.n., n.C.L. Oxon., LL.I>. Cantah. 

A Practical Treatise on Foreign Bodies in the Air-passages. In one 

octavo volume of 452 pages, with 59 illustrations. Cloth, $2.75. 



COHBN, J. SOLIS, M. I)., 

Lecturer on Laryngoscopy and Diseases of the Throat and Chest in the Jefferson Medical College. 

Diseases of the Throat and Nasal Passages. A Guide to the Diagnosis and 
Treatment of Affections of the Pharynx, (Esophagus, Trachea, Larynx and Nares. Third 
edition, thoroughly revised and rewritten, with a large number of new illustrations. In 
one very handsome octavo volume. Preparing. 



BBOAJDBBNT, W. BE., M. B., B. B. C. JP., 

Physician to and Lecturer on Medicine at St. Mary's Hospital. 
The Pulse. In one 12mo. volume. Preparing. See Series of Clinical Manuals, page 4. 



FULLER ON DISEASES OF THE LUNGS AND 
AIR-PASSAGES. Their Pathology, Physical Di- 
agnosis, Symptoms and Treatment. From the 
second and revised English edition. In one 
octavo volume of 475 pages. Cloth, $3.50. 

WALSHE ON THE DISEASES OF THE HEART 
AND GREAT VESSELS. Third American edi- 
tion. In 1 vol. 8vo.. 416 pp. Cloth, 83.00. 

BLADE ON DIPHTHERIA; its Nature and Treat- 
ment, with an account of the History of its Pre- 



valence in various Countries. Second and revised 
edition. In one 12mo. vol., pp. 158. Cloth, $1.25. 

SMITH ON CONSUMPTION ; its Early and Reme- 
diable Stages. 1 vol. 8vo., pp. 253. Cloth, $2.25. 

LA ROCHE ON PNEUMONIA. 1 vol. 8vo. of 490 
pages. Cloth, $3.00. 

WILLIAMS ON PULMONARY CONSUMPTION; 
its Nature, Varieties and Treatment. With an 
analysis of one thousand cases to exemplify its 
duration. In one 8vo. vol. of 303 pp. Cloth, $2.50. 



Lea Brothers & Co.'s Publications — Nerv. and Ment. I>is., etc. 19 



one octavo 



BOSS, JAMES, M.n., F.JEt. C.B., LL. JD., 

Senior Assistant Physician to the Manchester Royal Infirmary. 

A Handbook on Diseases of the Nervous System. In 

volume of 725 pages, with 184 illustrations. Cloth, $4.50 ; leather, $5.50. 

This admirable work is intended for students of 
medicine and for such medical men as have no time 
for lengthy treatises. In the present instance the 
duty of arranging the vast store of material at the 



disposal of the author, and of abridging the de- 
scription of the different aspects of nervous dis- 
eases, has been performed with singular skill, and 
the result is a concise and philosophical guide to 



the department of medicine of which it treats. 
Dr. Ross holds such a high scientific position that 
any writings which bear his name are naturally 
expected to have the impress of a powerful intel- 
lect. In every part this handbook merits the 
highest praise, and will no doubt be found of the 
greatest value to the student as well as to the prac- 
titioner. — Edinburgh Medical Journal, Jan. 1887. 



MITCHELL, S. WEIB, M. n., 

Physician to Orthopaedic Hospital and the Infirmary for Diseases of the Nervous System, Phila., etc. 

Lectures on Diseases of the Nervous System; Especially in Women. 
Second edition. In one 12mo. volume of 288 pages. Cloth, $1.75. 

No work in our language develops or displays 
more features of that many-sided affection, hys- 



teria, or gives clearer directions for its differen- 
tiation, or sounder suggestions relative to its 
general management and treatment. The book 
is particularly valuable in that it represents in 
the main the author's own clinical studies, which 
have been so extensive and fruitful as to give his 



teachings the stamp of authority all over the 
realm of medicine. The work, although written 
by a specialist, has no exclusive character, and 
the general practitioner above all others will find 
its perusal profitable, since it deals with diseases 
which he frequently encounters and must essay 
to treat. — American Practitioner, August, 1885. 



MAMILTOW, ALLA^ McLAJSTE, M. jD., 

Attending Physician at the Hospital for Epileptics and Paralytics, BlackweWs Island, N. 7. 
Nervous Diseases ; Their Description and Treatment. Second edition, thoroughly 
revised and rewritten. In one octavo volume of 598 pages, with 72 illustrations. Cloth, $4. 

characterized this book as the best of its kind in 



When the first edition of this good book appeared 
we gave it our emphatic endorsement, and the 

g resent edition enhances our appreciation of the 
ook and its author as a safe guide to students of 
<^linical neurology. One of the best and most 
critical of Englisn neurological journals, Brain, has 



any language, which is a handsome endorsement 
from an exalted source. The improvements in the 
new edition, and the additions to it, will justify its 
purchase even by those who possess the old. — 
Alienist and Neurologist, April, 1882. 



TUKE, DAWIEL HACK, M. !>., 

Joint Author of The Manual of Psychological Medicine, etc. 

Illustrations of the Influence of the Mind upon the Body in Health 
and Disease. Designed to elucidate the Action of the Imagination. New edition. 
Thoroughly revised and rewritten. In one 8vo. vol. of 467 pp., with 2 col. plates. Cloth, $3. 



It is impossible to peruse these interesting chap- 
ters without being convinced of the author's per- 
fect sincerity, impartiality, and thorough mental 
grasp. Dr. Tuke has exhibited the requisite 
amount of scientific address on all occasions, and 
the more intricate the phenomena the more firmly 
has he adhered to a physiological and rational 



method of interpretation. Guided by an enlight- 
ened deduction, the author has reclaimed for 
science a most interesting domain in psychology, 
previously abandoned to charlatans and empirics. 
This book, well conceived and well written, must 
commend itself to every thoughtful understand- 
ing.— iVezo York Medical Journal, September 6, 1884. 



CLOJJSTON, THOMAS S., M. D., F. JR. C. F., L. B. C. S., 

Lecturer on Mental Diseases in the University of Edinburgh. 

Clinical Lectures on Mental Diseases. With an Appendix, containing an 
Abstract of the Statutes of the United States and of the Several States and Territories re- 
lating to the Custody of the Insane. By Charles F. Folsom, M. D., Assistant Professor 
of Mental Diseases, Med. Dep. of Harvard Univ. In one handsome octavo v'oiume oi 541 
pages, with eight lithographic plates, four of which are beautifully colored. Cloth, $4. 

The practitioner as well as the student will ac- 
cept the plain, psactical teaching of the author as a 
forward step in the literature of insanity. It is 



the general practitioner in guiding him to a diag- 
nosis and indicating the treatment, especially in 
many obscure and doubtful oases of mental dis- 
ease. To the American reader Dr. Folsom's Ap- 
pendix adds greatly to the value of the work, and 
will miiie it a desirable addition to every library. 
—American Psychological Jownal, July, 1854. 



refreshing to find a physician of Dr. Clouston's 
experience and high reputation giving the bed- 
side notes upon which nis experience has been 
founded and his mature judgment established. 
Such clinical observations cannot but be useful to 

8@*Dr. Folsom's Abstract may also be obtained separately in one octavo volume of 
108 pages. CJioth, $1.50. 

SAVAGE, GEOBGE H., M. L>., 

Lecturer on Mental Diseases at Ouy's Hospital, London. 

Insanity and Allied Neuroses, Practiciil and Clinioal. In one 12mo. vol. 
of 551 i)ages, with 18 illus. Clo.th, $'2.00. See Scries of Clinical Mamuih, page 4. 

PLAYEAIB, W. S^ M. D., fTb. C. JP. 

The Systematic Treatment of Nerve Prostration and Hysteria. In 

one handsome small TJmo. volume of 97 pjiges. Cloth, $1.00. 

Blandford on Insanity and its Treatment; lecture* on the Treauuent, 

Medical and Legal, of Insjine PHtieuls. In one very handsome ootavo volume. 

Jones' Clinical Observations on Functional Nervous Disorders. 
Second American Edition. In one handsome octavo voluino o( 'MO pages. Cloth, 5^0. "Jo. 



20 



Lea Brothers & Co.'s Publications — Surgery. 



ASHBTfBST, JOHJST, Jr., M. JD., 

Professor of Clinical Surgery, Univ. of Penna., Surgeon to the Episcopal Hospital, Philadelphia. 

The Principles and Practice of Surgery. New (fourtli) edition, enlarged 
and revised. In one large and handsome octavo volume of 1114 pages, with 597 illustra- 
tions. Cloth, $6 ; leather, $7. 



As with Erichsen so with Ashhurst, its position 
in professional favor is established, and one has 
now but to notice the changes, if any, in theory 
and practice, that are apparent in the present 
as compared with the preceding edition, published 
three years ago. The work has been brought well 
up to date, and is larger and better illustrated than 
before, and its author may rest assured that it will 
certainly have a " continuance of the favor with 
which it has heretofore been received."— T/ie 
American Journal of the Medical Sciences, Jan. 1886. 



Every advance in surgery worth notice, chroni- 
cled in recent literature, has been suitably recog- 
nized and noted in its proper place. Sufl&ce it u> 
say, we regard Ashhurst's Surgery, as now pre- 
sented in the fourth edition, as the best single 
volume on surgery published in the English lan- 
guage, valuable alike to the student and the prac- 
titioner, to j;he one as a text-book, to the other as 
a manual of practical surgery. With pleasure we 

give this volume our endorsement in full. — New 
cleans Medical and Surgical Journal, Jan., 1886. 



GBOSS, S. 2>., M. JD., LL. JD., D. C. L. Oxon., LL. 2). 
Cantab, f 

Emeritus Professor of Sv/rgery in the Jefferson Medical College of Philadelphia. 
A System of Surgery : Pathological, Diagnostic, Therapeutic and Operative. 
Sixth edition, thoroughly revised and greatly improved. In two large and beautifully- 
printed imperial octavo volumes containing 2382 pages, illustrated by 1623 engravings; 
Strongly bound in leather, raised bands, |15. 

His System oj Surgery, which, since its first edi- 
tion in 1859, has been a standard work in this 



Dr. Gross' System of Suraery has long been the 
standard work on that subject for students and 
practitioners. — London Lancet, May 10, 1884. 

The work as a whole needs no commendation. 
Many years ago it earned for itself the enviable 
reputation of the leading American work on sur- 
gery, and it is still capable of maintaining that 
standard. A consideraole amount of new material 
has been introduced, and altogether the distin- 

fuished author has reason to be satisfied that he 
as placed the work fully abreast of the state of 
our knowledge.— ilfed. Record, Nov. 18, 1882. 



country as well as in America, in "the whole 
domain of surgery," tells how earnest and labori- 
ous and wise a surgeon he was. how thoroughly 
he appreciated the work done by men in other 
countries, and how much he contributed to pro- 
mote the science and practice of surgery in his 
own. There has been no man to whom America 
is so much indebted in this respect as the Nestor 
of surgery.— ^ritw^i Medical Journal, May 10, 1884. 



DBUITTf BOBJEBT, M. B. C. S., etc. 

Manual of Modern Surgery. Twelfth edition, thoroughly revised by Stan- 
ley Boyd, M. B., B. S., F. E. C. S. In one 8vo. volume of 965 pages, with 373 illustra- 
tions. Cloth, $4; leather, $5. 



It is essentially a new book, rewritten from be- 
ginning to end. The editor has brought his work 
up to the latest date, and nearly every subject on 
wnich the student and practitioner would desire 
to consult a surgical volume, has found its place 
here. The volume closes with about twenty pages 
of formulee covering a broad range of practical 
therapeutics. Th* student will find that the new 
Druitt is to this generation what the old one was 
to the former, and no higher praise need be 
accorded to any volume.— iV^rt/i Carolina Medical 
Jowrnal, October, 1887. 



Druitt's Surgery has been an exceedingly popu- 
lar work in the profession. It is stated that 50,000 
copies have been sold in England, while in the 
United States, ever since its first issue, it has been 
used as a text-book to a very large extent. Dur- 
ing the late war in this country it was so highly 
appreciated that a copy was issued by the Govern- 
ment to each surgeon. The present edition, while 
it has the same features peculiar to the work at 
first, embodies all recent discoveries in surgery, 
and is fully up to the times. Cincinnati M&iical 
News, September, 1887. 



BALL, CMABLBS B., M. Ch., Dub., F. B. C. S. B., 

Surgeon and Teacher at Sir P. Dun's Hospital, Dublin. 

Diseases of the Rectum and Anus. In one 12mo. volume of 417 
with 54 engravings and 4 colored plates. Cloth, |2.25. Just ready. See Series of Clinical 
Manuals, page 4. 



It is a pleasure to read an exhaustive and well- 
arranged book, such as the one before us. It 
covers all the ground, and yet is written in a terse 
and concise style that makes it exceedingly good 
reading. The work is far in advance of the ordi- 
nary text-book on this specialty. It is very com- 
plete, and the matter is all of practical importance 
and well arranged. The writer has done for rectal 
surgery what Treves in the companion volume 



has done for intestinal obstruction, and both 
works are alike creditable. — N. Y. Medical Journal^ 
Jan. 28, 1888. 

A capital book in a capital series of clinical 
manuals. Thoroughly practical, it is both compre- 
hensive and condensed and the possessor of it will 
find but little use for any more extended work on 
the subject. Mr. Ball is a most sound surgeon. — 
The Medical News, Feb. 4, 1888. 



GIBJSBT, V. JP., M. jy., 

Surgeon to the Orthopaedic Hospital, New York, etc. 
Orthopaedic Surgery. For the use of Practitioners and Students, 
some octavo volume, profusely illustrated. Preparing. 



In one hand- 



BOBBBTS, J. B., M. D., and MOBTON, T. S. K., M. D.^ 

Professor of Anatomy and Surgery in the Adjunct Professor of Operative Surgery in the 

Philadelphia\Polyclinic. Philadelphia Polyclinic. 

The Principles and Practice of Modern Surgery. For the use of Students 
and Practitioners of Medicine and Surgery. In one very handsome octavo volume of about 
600 pages, with many illustrations. Preparing. 



Lea Brothers & Co.'s Publications — Surgery* 



21 



bhichsen, josn je., f. it. s., f. h. c. s., 

Professor of Surgery in University College, London, etc. 

The Science and Art of Surgery ; Being a Treatise on Surgical Injuries, Dis- 
eases and Operations. From the eighth and enlarged English edition. In two large and 



beautiful octavo volumes of 2316 pages, 
Cloth, $9; leather, raised bands, |11. 

We have always regarded "The Science and 
Art of Surgery" as one of the best surgical text- 
books in the English language, and this eighth 
edition only confirms our previous opinion. We 
take great pleasure in cordially commending it to 
our XQdkdiers.— The Medical News, April 11, 1885. 

For many years this classic work has been 
made by preference of teachers the principal 
text-book on surgery for medical students, while 
through translations into the leading continental 
languages it may be said to guide the surgical 
teachings of the civilized world. No excellence 
of the former edition has been dropped and no 
discovery, device or improvement which has 



illustrated with 984 engravings on wood. 

marked the progress of surgery during the last 
decade has been omitted. The illustrations are 
many and executed in the highest style of art. 
— Louisville Medical News, Feb. 14, 1885. 

We cannot speak too highly of this excellent 
work. It represents the most advanced and settled 
views in regard to the science of surgery, and will 
ever be found a faithful guide and counsellor in 
practice. — Canada Lancet, May, 1885. 

It appears simultaneously in England, America, 
Sf>ftin and Italy, and is too well known as a safe 
guide and familiar friend to need further com- 
ment.— iV^eio York Modical Journal, March 28, 1885. 



BUYANT, TMOMA8, F. It. C. S., 

Surgeon and Lecturer on Surgery at Quy^s Hospital, London. 
The Practice of Surgery. Fourth American from the fourth and revised Eng- 
lish edition. In one large and very handsome imperial octavo volume of 1040 pages, with 
727 illustrations. Cloth, $6.50; leather, $7.50. 



The fourth edition of this work is fully abreast 
of the times. The author handles his subjects 
with that degree of judgment and skill which is 
attained by years of patient toil and varied ex- 
perience. The present edition is a thorough re- 
vision of those which preceded it, with much new 
matter added. His diction is so graceful and 
logical, and his explanations are so lucid, as to 

Elace the work among the highest order of text- 
ooks for the medical student. Almost every 
topic in surgery is presented in such a form as to 



enable the busy practitioner to review any subject 
in every-day practice in a short time. No time is 
lost with useless theories or superfluous verbiage. 
In short, the work is eminently clear, logical and 
practical,— C%ica£?o MedicalJournal and Examiner, 
April, 1886. 

This book is essentially what it purports to be, 
viz.: a manual for the practice of surgerv. It is 
peculiarly wel? fitted for the student or busy general 
practitioner.— r/ie Medical News, August 15, 1885. 



TBFVBS, FMFDFMICJS:, F. It. C. S., 

Hunterian Professor at the Royal College of Surgeons of England. 
A Manual of Surgery. In Treatises by Various Authors. In three 12mo. 
volumes, containing 1866 pages, with 213 engravings. Price per volume, cloth, $2. See 
Students' Series of Manuals, page 4. 

the salient points and the beginnings of new sub- 
jects are always printed in extra-heavy type, so 
that a person may find whatever information he 
may be in need of at a moment's glance. — Cin- 
cinnati Lancet-Clinic, August 21, 1386. 



We have here the ojinions of thirty-three 
authors, in an encyclopaedic form for easy and 
ready reference. The three volumes embrace 
every variety of surgical affections likely to be 
met with, the paragraphs are short and pithy, and 



MABSH, SOWAItn, F. It. C. S., 

Senior Assistant Surgeon to and Lecturer on Anatomy at St. Bartholomew's Hospital, London. 
Diseases of the Joints. In one 12mo. volume of 468 pages, with 64 woodcuts 
and a colored plate. Cloth, $2.00. See /Series of Clinical Manuals, page 4. 

BUTLIN, SFWItY T., F. It. C. S., 

Assistant Surgeon to St. Bartholomew's Hospital, London. 

Diseases of the Tongue. In one 12mo. volume of 456 pages, with 8 colored 
plates and 3 woodcuts. Cloth, $3.50. See Series of Clinical 3Ianuals, .page 4. 

The language of the text is clear and concise. " ' 

The author has aipaed to state facts rather than to 
express opinions, and has compressed within the 
compass of this small volume the pathology, etiol- 
ogy, etc., of diseases of the tongue that are incon- 



veniently scattered through general works on sur- 
gery and the practice of medicine. The phvsician 
and surgeon will appreciate its value as an aid and 
guide.— Physician and Surgeon, Sept. 1SS6. 



TBEVFS, FltFDFItlCK, F. B. C. 8., 

Surgeon to and Lecturer on Surgei-j/ at the London Hospital. 

Intestinal Obstruction. In one pocket-size 12mo. volume of 522 pages, with 60 

^'"^^ See Series of Clinical Manuals, page 4. 

justice to the author in a few pans^raphs. Intes- 
tinal Ohstmction is a work that vvill prove of 
equal value to the practitioner, the student, the 



illustrations. Limp cloth, blue edges, $ 

bie 
BO comprehensively treated b 



.00. 



A standard work on a subject that has not been 
Iv 
EnglisH writer. Its completeness renders* a full 



3y any contemporary 



review ditiicult, since every chapter deserves mi- 
nute attention, and it is impossible to do thorough 



pathologist, the physician and the operating sur- 
geon.— £rt/lk}/» Aledieal Journal, Jan. 31, 18So. 



GOVLD, A. I>FABCF, M. S., M. B., F. B. €. S., 

Assistant Surgeon to Middlesex Hospital. 

Elements of Surgical Diagnosis. In one pocket-size 12mo. volume of 5S9 
pages. Cloth, $2.00. See Studetits' Series of Manuals, page 4. 



PIRRIE'S PRINCIPLES AND PRACTICE OF 
SURGERY. Edited by John Nkill, I\[. D. In 
one 8vo. vol. of 784 pp. with aid ilhis>. Cloth. 8ii.75. 

MILLER'S PRINCIPLES OF SURGERY. Fourth 
American from the third Edinburgh edition. In 



one 8vo. vol. of iVW pages, with S40 illustrations, 
'"loth. $3.75. 
MILLER'S PRACTICE OF SURGERY. Fourth 
and revised .\morioan edition. In one lars** Svo. 
vol. of 6S2 pp., with SG4 illustrations. Cloth. |».7v\ 



22 Lea Brothers & Co.'s Publications — Surgery* Frac., Disioc, 



SMITH, STEJPHJEJS^, M. D., 

Professor of Clinical Surgery in the University of the City of New York. 

The Principles and Practice of Operative Surgery. New (second) and 
thoroughly revised edition. In one very handsome octavo volume of 892 pages, with 



1005 illustrations. Cloth, $4.00; leather, $5.00 



This excellent and very valuable book is one of 
the most satisfactory works on modern operative 
surgery yet published. Its author and publisher 
have spared no pains to make it as far as possible 
an ideal, and their efforts have given it a position 
prominent among the recent works in this depart- 
ment of surgery. The book is a compendium for 
the modern surgeon. The present, the only revised 
edition since 1879, presents many changes from 
the original manual. The volume is much en- 
larged, and the text has been thoroughly revised, 
so as to give the most improved methods in asep- 



tic surgery, and the latest instruments known foi 
operative work. It can be truly said that as a hand- 
book for the student, acompanion forthe surgeon, 
and even as a book of reference for the physician 
not especially engaged in the practice oj surgery, 
this volume will long hold a most conspicuous 
place, and seldom will its readers, no matter how 
unusual the subject, consult its pages in vain. Its 
compact form, excellent print, numerous illustra- 
tions, and especially its decidedly practical char- 
acter, all combine to commend it. — Boston Medical 
and Surgical Journal, May 10, 1888. 



SOLMES, TIMOTHY, M. A., 

Surgeon and Lecturer on Surgery at St. George's Hospital, London. 

A Treatise on Surgery ; Its Principles and Practice. New American 

from the fifth English edition, edited by T. Pickering Pick, F. E. C. S., Surgeon and 
Lecturer on Surgery at St. George's Hospital, London. In one octavo volume of 997 
pages, with 428 illustrations. Cloth, $6 ; leather, $7. Jiist ready. 



To the younger members of the profession and 
to others not acquainted with the book and its 
merits, we take pleasure in recommending it as a 
surgery complete, thorough, well-written, fully- 
illustrated, modern, a work sufficiently volumi- 
nous for the surgeon specialist, adequately concise 



for the general practitioner, teaching those things 
that are necessary to be known for the successful 
prosecution of the physician's career, imparting 
nothing that in our present knowledge is consid- 
ered unsafe, unscientific or inexpedient. — Pacific 
Medical Journal, July, 1889. 



HOLMES, TIMOTHT, M. A., 

Surgeon and Lecturer on Surgery at St. George's Hospital, London. 

A System of Surgery; Theoretical and PracticaL IN TREATISES BY 

VAEIOUS AUTHORS. American edition, thoroughly revised and re-edited 
by John H. Packard, M. D., Surgeon to the Episcopal and St. Joseph's Hospitals, 
Philadelphia, assisted by a corps of thirty-three of the most eminent American surgeons. 
In three large imperial octavo volumes containing 3137 double-columned pages, with 
979 illustrations on wood and 13 lithographic plates, beautifully colored. Price per 
set, cloth, $18.00; leather, $21.00. Sold only by subscription. 

STIMSOJ^, LEWIS A., B. A., M. 2>., 

Surgeon to the Presbyterian and Bellevue Hospitals, Professor of Clinical Surgery in the Medical 
Faculty of Univ. of City of N. Y., Corresponding Member of the Societe de Chirurgie of Paris. 

A Manual of Operative Surgery. New (second) edition. In one very hand- 
some royal 12mo. volume of 503 pages, with 342 illustrations. Cloth, $2.50. 



There is always roorn for a good book, so that 
while many works on operative surgery must be 
considered superfluous, that of Dr. Stimson has 
held its own. The author knows the difficult art 
of condensation. Thus the manual serves as a 
work of reference, and at the same time as a 
handy guide. It teaches what it professes, the 
steps of operations. In this edition Dr. Stimson 
has sought to indicate the changes that have been 



effected in operative methods and procedures by 
the antiseptic system, and has added an account 
of many new operations and variations in the 
steps of older operations. We do not desire to 
extol this manual above many excellent standard 
British publications of the same class, still we be- 
lieve that it contains much that is worthy of Imi- 
tation. — British Medical Journal, Jan. 22, 1887. 



By the same Author. 
A Treatise on Fractures and Dislocations. In two handsome octavo vol- 
umes. Vol. I., Fractures, 582 pages, 360 beautiful illustrations. Vol. II., Disloca- 
tions, 540 pages, with 163 illustrations. Complete work just ready, cloth, $5.50 ; leather, 
$7.50. Either volume separately, cloth, $3.00; leather, $4.00. 



The appearance of the second volume marks the 
completion of the author's original plan of prepar- 
ing a work which should present in the fullest 
manner all that is known on the cognate subjects 
of Fractures and Dislocations. The volume on 
Fractures assumed at once the position of authority 
on the subject, and its companion on Dislocations 
will no doubt be similarly received. The closing 
volume of Dr. Stimson's work exhibits the surgery 



of Dislocations as it is taught and practised by the 
most eminent surgeons of the present time. Con- 
taining the results of such extended researches it 
must for a long time be regarded as an authority 
on all subjects pertaining to dislocations. Every 

Eractitioner of surgery will feel it incumbent on 
im to have it for constant reference.— CtrMsinnaft 
Medical News, May, 1888. 



HAMILTOJ^, FBAJVJB: H., M. D., LI. 2>., 

Surgeon to Bellevue Hospital, New York. 

A Practical Treatise on Fractures and Dislocations. Seventh edition 
thoroughly revised and much improved. In one very handsome octavo volume of 998 
pages, with 379 illustrations. Cloth, $5.50; leather, $6.50. 



'his book is without a rival in any language. It 
is essentially a practical treatise, and it gathers 
within its covers almost everything valuable that 
has been written about fractures and dislocations. 
The principles and methods of treatment are very 



fully given. The book is so well known that it does 
not require any lengthened review. We can only 
say that it is still unapproached as a treatise. — 
The Dublin Journal of Medical Science, Feb. 1886. 



I'ICK, T. BICKERING, F. B. C. S., 

Surgeon to and Lecturer on Surgery at St. George's Hospital, London. 

Fractures and Dislocations. In one 12mo. volume of 530 pages, with 93 

illustrations. Limp cloth, $2.00. See Series of Clinical Manuals, page 4. 



Lea Brothers & Co.'s Publications — OtoL, Ophtlial, 



23 



BUMJ^JETT, CIIABLES 11., A. 31., 31. JJ., 

Professor of Otology in the Philadelphia Polyclinic ; President of the American Otological Society. 

The Ear, Its Anatomy. Physiology and Diseases. A Practical Treatise 
for the use of Medical Students and Practitioners. Second edition. In one handsome 
octavo volume of 580 pages, with 107 illustrations. Cloth, $4.00 ; leather, $5.00. • 

carried out, and much new matter added. Dr. 
Burnett's work mu.st Vje regarded as a very valua- 
ble contribution to aural .surgery, not only oa 
account of its connprehensiveness, but becauf-e it 
contains the results of the careful persona! observa- 
tion and experience of this eminent aural surgeon. 
—London Lancet, Feb. 21. 1885. 



We note with pleasure the appearance of a second 
edition of this valuable work. When it first came 
Dut it was accepted by the profession as one of 
the standard works on modern aural surgery in 
the English language; and in his second edition 
Dr. Burnett has fully maintained his reputation, 
for the book is replete with valuable information 
and suggestions. The revision has been carefully 



POLITZEM, AI>A3I, 

pinperialr Royal Prof, of Aural Therap. in the Univ. of Vienna. 

A Text-Book of the Ear and its Diseases. Translated, at the Author's re- 
quest, by James Patterson Cassells, M. D., M. R. C, S. In one handsome octavo vol- 
ume of 800 pages, with 257 original illustrations. Cloth, $5.50. 

The whole work can be recommended as a reli- I the practitioner in his treatment. — Boston Medical 
able guide to the student, and an efficient aid to j and Surgical Journal, June 7, 1883. 

JVLEB, MENBY JE., F. M. C. S., 

Senior Ass't Surgeon, Royal Westminster Ophthalmic Hosp.; hvte Clinical Ass't, Moorfields, London. 

A Handbook of Ophthalmic Science and Practice. In one handsome 
octavo volume of 460 pages, with 125 woodcuts, 27 colored plates, selections from the 
Test-types of Jaeger and Snellen, and Holmgren's Color-blindness Test. Cloth, $4.50 ; 
leather, $5.50. 

It presents to the student concise descriptions 
and typical illustrations of all important eye affec- 
tions, placed in juxtaposition, so as to be grasped 
at a glance. Beyond a doubt it is the best illus- 
trated handbook of ophthalmic science which has 
ever appeared. Then, what is still better, these 



illustrations are nearly all original. We have ex- 
amined this entire work with great care, and it 
represents the commonly accepted views of ad- 
vanced ophthalmologists. We can most heartily 
commend this book to all medical students, prac- 
titioners and specialists. — Detroit Lancet, Jan. '85. 



^BTTLESJEEIJP, EDWAMD, JF. M. C. S., 

Ophthalmic Surg, and Led. on Ophth. Surg, at St. Thomas' Hospital, London. 

The Student's Guide to Diseases of the Eye. New (third) edition, thor- 
oughly revised. With a chapter on the Detection of Color-Blindness, by William 
Thomson, M. D., Professor of Ophthalmology in the Jefferson Medical College. In one 
12mo. volume of 479 pages, with 164 illust., test-types and formulae. Cloth, %2. 

in the chapter devoted to operations. A very 
important part of the work to general practitioners 
is tnat embraced in the consideration of eye dis- 
eases in relation to general diseases and 'condi- 
tions. The arrangement of the remedies employed 
into a formulary is adopted, and it contains much 
duetion, and this is nowhere more apparent than | useful knowledge. — South. Practitioner, Dec. 1S87. 



The extent of the sale of this now accepted 
authority has conclusively shown that its claim for 
favor was not an imaginary one. The introductory 
chapter on optical outlines is a wonderfully clear 
statement of the principles involved. The writer's 
decision of character has fully impressed his pro- 
thi 



NOMRIS, W3l. F., 3f. D., and OLIVEB, CMAS. A., 31. D. 

Clin. Prof, of Ophthalmology in Univ. of Pa. 
A Text-Book of Ophthalmology. In one octavo volume of about 500 pages, 
with illustrations. Preparing. 

CAHTEJR, B. BBUDENELL, & frost, W.AI>A3IS, 

F. M. C. S., F. B. C. S., 

Ophthalmic Surgeon to and Lecturer on Oph- Assistant Ophthalmic Surgeon to and Joint 

ihalmic Surgerry at St. George's Hospital, Lecturer on Ophthalmic Surgciy at St, 

London. Oeorge^s Hospital, London. 

Ophthalmic Surgery. In one 12mo. volume of 559 pages, with 91 woodcuts, 
cx)lor blindness test, test-types and dots and appendix of Ibrmulfe. Cloth, |2.25. See 
Series of Clinical Manuals, page 4. 

WELLS, J. SOELBEHG, F.M. C. S., 

Professor of Ophthalmology in Kinq's College Hospital, London, etc. 

A Treatise on Diseases of the Eye. New (tifth) American from the third 
London edition. In one large octavo volume. Pi'cpariny. 

BBOWWE, EBGABA7, 

Surgeon to the Liverpool Eye and Ear Infirmary and to the Dispcnsniy for Skin Diseases, 

How to Use the Ophthalmoscope. Being Elementary Instruction 
thalmoscopy, arranged for the use of Students. 
pages, with 35 illustrations. Cloth, $1.00. 



In one small roval TJuio. 



in Oph- 

volume o( 116 



LAURENCE AND MOON'S HANDY BOOK OF 
OPHTHALMIC SURGERY, for the use of Prac- 
titioners. Second edition. In one octAvo vol- 
ume of 227 pages, with G6 illus. Cloth, $2.75. 



LAWSON ON INJURIES TO THE EYE, ORBIT 
AND EYELIDS: Their Immediate and Kemot* 
Effects. 8 vo., 4<M pp., 92 illus. Cloth, 53,^i). 



24 Lea Brothers & Co.'s Publications — Uriii. Dis., Dentistry, etc. 



BOBJEBTS, WILLIAM, M. 2)., 

Lecturer on Medicine in the Manchester School of Medicine, etc. 

A Practical Treatise on Urinary and Renal Diseases, including Uri- 
nary Deposits. Fourth American from the fourth London edition. In one hand- 
some octavo vohime of 609 pages, with 81 illustrations. Cloth, $3.50, 

It may be said to be the best book in print on the 
subject of which it treats. — The American Journal 



of the Medical Sciences, Jan. 1886. 

The peculiar value and finish of the book are in 
a measure derived from its resolute maintenance 
of a clinical and practical character. It is an un- 
rivalled exjiosition of everything which relates 
directly or indirectly to the diagnosis, prognosis 
and treatment of urinary diseases, and possesses 
a completeness not found elsewhere in our lan- 



guage in its account of the diflFerent affections.— 
The Manchester Medical Chronicle, July, 1885. 

The value of this treatise as a guide book to the 
physician in daily practice can hardly be over- 
estimated. That it is fully up to the level of our 
present knowledge is a fact reflecting great credit 
upon Dr. Roberts, who has a wide reputation as a 
busy practitioner.— r/ie Medical Record, July 31, 



rVBDY, CSABLBS W., M. 2>., Chicago. 

Bright's Disease and Allied Affections of the Kidneys. In one octavo 

volume of 288 pages, with illustrations. Cloth, $2. 



The object of this work is to "furnish a system- 
atic, practical and concise description of the 
pathology and treatment of the chief organic 
diseases of the kidney associated with albuminu- 
ria, which shall represent the most recent ad- 
vances in our knowledge on these subjects ; " and 
this definition of the object is a fair description of 
the book. The work is a useful one, giving in a 



short space the theories, facts and treatments, and 
going more fully into their later developments. 
On treatment the writer is particularly strong, 
steering clear of generalities, and seldom omifc- 
ting, what text-books usually do, the unimportant 
items which are all important to the general prac- 
titioner. — The Manchester Medical Chronicle, Oct. 



MOBBIS, SBJSTBT, M. B., F. B. C. S., 

Surgeon to and Lecturer on Surgery at Middlesex Hospital, London. 

Surgical Diseases of the Kidney. In one 12mo. volume of 554 pages, with 40 
woodcuts, and 6 colored plates. Limp cloth, $2.25. See Series of Clinical Manuals, page 4. 



In this manual we have a distinct addition to 
surgical literature, which gives information not 
elsewhere to be met with in a single work. Such 
a book was distinctly required, and Mr. Morris 
has very diligently and ably performed the task 



he took in hand. It is a full and trustworthy 
book of reference, both for students and prac- 
titioners in search of guidance. The illustrations 
in the text and the chromo-lithographs are beau- 
tifully executed. — The London Lancet, Feb. 26, 1886. 



LUCAS, CLJEMEWT, M. B., B. 8., F. B. C. S., 

Senior Assistant Surgeon to Ouy^s Hospital, London. 
Diseases of the Urethra. In one 12mo. volume. Preparing. See Series 
of Clinical Manuals, page 4. 

TSOMBSON, SIB HENBY, 

Surgeon and Professor of Clinical Surgery to University College Hospital, London. 

Lectures on Diseases of the Urinary Organs. Second American from the 
third English edition. In one Svo. volume of 203 pp., with 25 illustrations. Cloth, $2.25. 

By the Same Author. 
On the Pathology and Treatment of Stricture of the Urethra and 
Urinary Fistulse. From the third English edition. In one octavo volume of 359 
pages, with 47 cuts and 3 plates. Cloth, $3.50. 

THE AMEBICAW SYSTEM OF DENTISTBT. 

In Treatises by Various Authors. Edited by Wilbur F. Litch, M. D., 
D. D. S., Professor of Prosthetic Dentistry, Materia Medica and Therapeutics in the 
Pennsylvania College of Dental Surgery. In three very handsome octavo volumes con- 
taining 3160 pages, with 1863 illustrations and 9 full page plates. Per volume, cloth, $6 ; 
leather, $7 ; half Morocco, gilt top, $8. The complete work is tww ready. For sale by 
subscription only. 



As an encyclopsedia of Dentistry it has no su- 

f)erior. It should form a part of every dentist's 
ibrary, as the information it contains is of the 
greatest value to all engaged in the practice of 
entistry. — American Jour. Dent. Set., Sept. 1886. 
A grand system, big enough and good enough 
and handsome enough for a monument (which 



doubtless it is), to mark an epoch in the history of 
dentistry. Dentists will be satisfied with it and 
proud of it— they must. It is sure to be precisely 
what the student needs to put him and keep him 
in the right track, while tne profession at large 
will receive incalculable benent from it. — OdonU>- 
graphic Journal, Jan. 1887. 



COLEMAN^ A., L. B. C. -P., F. B. C. S., Exam. L. D. S., 

Senior Dent. Su/rg. and Lect. on Dent. Surg, at St. Bartholomew'' s Hosp. and the Dent. Hosp., London. 

A Manual of Dental Surgery and Pathology. Thoroughly revised and 
adapted to the use of American Students, by Thomas C. Stellwagen, M. A., M. D., 
D. D. S., Prof, of Physiology in the Philadelphia Dental College. In one handsome octavo 
volume of 412 pages, with 331 illustrations. Cloth, $3.25. 



_ It should be in the possession of every practi- 
tioner in this country. The part devoted to first 
and second dentition and irregularities in the per- 
manent teeth is fully worth the price. In fact, 
price should not be considered in purchasing such 
a work. If the money put into some of our so- 
called standard text-books could be converted into 
such publications as this, much good would result. 
—Southern Dental Journal, May, 1882. 



The author brings to his task a large experience 
acquired under the most favorable circumstances. 
There have been added to the volume a hundred 
pages by the American editor, embodying the 
views of the leading home teachers in dental sur- 
gery. The work, therefore, may be regarded as 
strictly abreast of the times, and as a very high 
authority on the subjects of which it treats. — 
American Practitioner, July, 1882. 



BASHAM ON RENAL DISEASES : A Clinical 
Guide to their Diagnosis and Treatment. In 



one 12mo. vol. of 304 pages, with 21 illustrations. 

Cloth, $2.00. 



Lea Brothers & Co.'s Publications — Venereal, Impotence. 



25 



GBOSS, SAMUBL W., A. M., M. JD., LL, JD., 

Professor of the Principles of Swrgery and of Clinical Swrgery in the Jefferson Medical College of Phila. 

A Practical Treatise on Impotence, Sterility, and Allied Disorders 
of the Male Sexual Organs. New (third) edition, thoroughly revised. In one very 
handsome octavo volume of 163 pages, with 16 illustrations. Cloth, $1.50. 



It must; be gratifying to both author and pub- 
lishers that large first and second editions of this 
little work were so soon exhausted, while the fact 
that it has been translated into Russian may indi- 
cate that it filled a void even in foreign literature. 
His is a careful and physiological study of the 
sexual act, so far as concerns the male, and all 
his conclusions are scientifically reached. The 
book has a place by itself in our literature, and 
furnishes a large fund of information concerning 
important matters that are too often passed over 
in silence. — The Medical Press, June, 1887. 



This now classical work on the subject of impo- 
tence and sterility in the male needs no extenaed 
review, for it is already well known to the pro- 
fession. Dr. Gross has by his tireless labor done 
more towards clearing up the diagnosis and treat- 
mentof these obscure cases than any other Ameri- 
can physician. The fact that this book has rapidly 
run through two large editions, and that the author 
is now forced to issue a third, is good and sufficient 
evidence of its exceUence.— Atlanta Medical and 
Surgical Journal, April, 1888. 



TATLOB, M. W., A. M., M. D., 

Surgeon to Charity Hospital, New York, Prof, of Venereal and Skin Diseases in the University of 
Vermont, Pres. of the Am. Dermatological Ass^n. 

The Pathologjr and Treatment of Venereal Diseases. Including the 
results of recent investigations upon the subject. Being the sixth edition of Bumstead 
and Taylor. Entirely rewritten by Dr. Taylor. Large and handsome 8vo. volume, 
about 900 pages, with about 150 engravings, as well as numerous chromo-lithographs. 
Preparing. 

A few notices of the previous edition are appended. 



It is a splendid record of honest labor, wide 
research, just comparison, careful scrutiny and 
original experience, which will always be held as 
a high credit to American medical literature. This 
is not only the best work in the English language 
upon the subjects of which it treats, but also one 
wnich has no equal in other tongues for its clear, 
comprehensive and practical handling of its 
themes. — Am. Jour, of the Med. Sciences, Jan, 1884. 

It is certainly the best single treatise on vene- 
re' in our own, and probably the best in any lan- 
guage. — Boston Med. and Surg. Journal, April 3, 1884. 

The character of this standard work is so well 



known that it would be superfluous here to pass In 
review its general or special points of excellence. 
The verdict of the profession has been passed; it 
has been accepted as the most thorough and com- 
plete exposition of the pathology and treatment of 
venereal diseases in the language. Admirable as a 
model of clear description, an exponent of sound 
pathological doctrine, and a guide for rational and 
successful treatment, it is an ornament to the medi- 
cal literature of this country. The additions made 
to the present edition are eminently judicious 
from the standpoint of practical utility.— Journal o/ 
Cutaneous and Venereal Diseases, Jan. 1884. 



COBJVIZ, F., 

Professor to the Faculty of Medicine of Paris, and Physician to the Lourcine Hospital. 

Syphilis, its Morbid Anatomy, Diagnosis and Treatment. Specially 
revised by the Author, and translated with notes and additions by J. Henry C. Simes, 
M. D., Demonstrator of Pathological Histology in the University of Pennsylvania, and 
J. William White, M*. D., Lecturer on Venereal Diseases and Demonstrator of Surgery 
in the University of Pennsylvania. In one handsome octavo volume of 461 pages, with 
84 very beautiful illustrations. Cloth, $3.75. 



The anatomy, the histology, the pathology and 
the clinical features of syphilis are represented in 
this work in their best, most practical and most 
Instructive form, and no one will rise from its 



perusal without the feeling that his grasp of the 
wide and important subject on which it treats is 
a stronger and surer one. — The London Practi' 
tioner, Jan. 1882. 



STITCJaiNSON, JONATHAN, F. M. S., F. B. C. S., 

Consulting Surgeon to the London Hospital. 
Syphilis. In one 12mo. volume of 542 pages, with 8 chromo-lithographs. 
$2.25. See Series of Clinical Manuals, page 4. 

Those who have seen most of the disease and 
those who have felt the real difficulties of diagno- 
sis and treatment will most highly appreciate the 
facts and suggestions which abound in these 
pages. It is a worthy and valuable record, not 
only of Mr. Hutchinson's very large experience 



Cloth, 



and power of observation, but of his patience and 
assiduity in taking notes of his cases and keep- 
ing them in a form available for such excellent 
use as he has put them to in this volume. — London 
Medical Record, Nov. 12, 1SS7. 



GBOS8, S. n., M. D., XX. X)., X). C. L., etc. 

A Practical Treatise on the Diseases, Injuries and Malformations 
of the Urinary Bladder, the Prostate Gland and the Urethra. Third 
edition, thoroughly revised by Samuel W. Gross, M. D. In one octavo volume of 574 
pages, with 170 illustrations. Cloth, $4,50. 

CVLLEBIBB, A., & BUMSTFAD, F. J., JL.U., LL.D., 

Surgeon to the Hdpital du MidL Late Professor of Venereal Di;ieas6S in the Colu-^e of Physicians 

and Surgeons, iSVco YorL 

An Atlas of Venereal Diseases. Translated and edited by Freeman J. Bum- 
9TEAI), M. D. In one imperial 4to. volume of 328 pajjes, double-oolumus, with -6 plates, 
containing about 150 figures, beautifully wlored, many of theiu the size o( lite. Stixnigly 
bound in cloth, $17.00. A specimen of the plates and text sent by mail, on receipt of 25 ct«. 

HILL ON SYPHILIS AND LOCAL CONTAGIOUS 1 FORMS O^pHlOCAL DISEASE AFFECTING 

OF GENEKA- 

>;'-., ?v> 25. 



DISORDERS. In one 8vo vol. of 479 p. Cloth, $:^.25. I PRINCIPALLY THE ORG.AN3 < 
LEE'S LECTURES ON SYPHILIS AND SOME , TION. lu one Svo. vol. of •J4<> rnco 



26 



Lea Brothers & Co.'s Publications — Venereal, Skin. 



TAYLOB, MOBJERT W., A.M., M.D., 

Surgeon lo Chnrity Hospital, New York, and to the Department of Venereal and Skin Diseases of 
the \\'tw York Hospital. 

A Clinical Atlas of Venereal and Skin Diseases: Including Diagnosis, 
Prognosis and Treatment. In eight large folio parts, measuring ]4 x 18 inclies, and 
comprising 58 beautifully-colored plates with 184 figures, and 425 pages of text with 85 
engravings. Complete work juU ready. Price per part, $2.50. Bound in one volume, 
half Kussia, $27 ; half Turkey Morocco, $28. For sale by subscription only. Specimen plates 
sent on receipt of 10 cents. A full prospectus sent to any address on application. 



This magnificent Clinical Atlas, we do not hesi- 
tate to say, will he regarded as one of the most 
valuable and handsome contributions to the medi- 
cal literature of the age. As its name implies, the 
Clinical Atlas is intended as a working guide for 
•any practitioner who chooses to deal with thewide- 
:spread class of chronic diseases included in its 
title. For the adequate accomplishment of its 

fiurpose such a work must comprise pictures, life- 
ike in form and color, of a size as large as is com- 
patible with convenience, together with a descrip- 
tive, clinical and didactic text. The entire litera- 
ture of the subjects has been searched for its best 
illustrations, and selections male with proper 
permission of living authors. These have been 
complemented by numerous reproductions from a 
■collection of original paintings from life, gathered 
•by the author durmg many years of practice. The 
•text has been designed to furnish the practitioner 
with clear and explicit directions for the proper 
management ( f his cases, and at the same time to 
stimulate tlie interest of those who may wish to 
dfvote their life-work to these subjects. A full 
statement of the clinical hi.-tory, varying features, 
etiology, diagnosis, and prognosis lias therefore 
been tollowet V)y definite and complete thera- 
peutical information. In their respective spheres 
the author and nuhlishers have left nothing undone 
to make the Clinical Atlas a work which will be 



recognized as a standard authority on its subjects. 
The strong faith of its publishers in the merit 
and wide appreciation which they must feel 
assured awaits the Clinical Atlas at the liands of a 
discriminating medical public is evidenced by 
the very moderate figure at which itU supplied, a 
figure so much below that customarily charged 
for works of this class that only the wiiestuis- 
semination can possibly bring them a fair return 
for their evidently lavish outlay. — Southern Prae- 
tition(r,S9pt, 1888. 

Viewing this collection a^' a whole it may be said 
that it is difficult to overestimate its clinical value 
to the practitioner and diagnostician. A careful 
study of even the smalle.-^t of these portraits of 
disease will repay the student. Their practical 
value in teaching is exactly proportioned to their 
faithfulness to fai't In the important matters of 
etiology ani treatment, the author is as lucid and 
practif'al as might be anticipat<>d from one of his 
experience and previous contributions to derma- 
tological literature. i>r Taylor's Atlas is to be 
warmly commended to the expert, the general 
practitioner, and the student, as an invaluable aid 
in acquiring a knowledge of the suhjeets illus- 
trated combining in a high degree the advantages 
of a sound textbook, with the special assistance 
of colored illu.'-trations.— T^Z/e .^wericmi Journal of 
the Medical Sciences, April, 1S89. 



HYDE, J. NEVi:S^S, A. 31., 31. D., 

Prcftssor of Dermatology and Venereal Diseases in Rush Medical College, Chicago. 

A Practical Treatise on Diseases of the Skin. For the use of Students and 
Practitioners. New (second) edition. In one handsome octavo volume of G76 pages, 
with 2 colored plates and 85 beautiful and elaborate illustrations. Cloth, $4.50 ; leather, 
$5.50. Just ready. 



We can heartily commend it, not only as an 
admirable text-book for teacher and student, but 
in its clear an. 1 comprehensive rales f >r diagnosis, 
its sound and independent doctrines in pathology, 
and its minute and judicious directions for the 
treatment of disease, as a most satisfactory and 
complete* practical guide for the physician — Ameri- 
can Journal, of the Medical Science^:, July, 1888. 

A useful glossary descriptive of terms is given. 
The descriptive portions of this work are plain 
and easily understood, and above all are very 
accurate. The therapeu'ical part is abunJantly 
supplied with exc'-llent recommendations. The 
picture pars is well done. The value ( f the work 
to practitioners is great because oi the excellence 
of the des:;riptions, the suggest! veness of the 
advice, and the correctn»^ss of the df tAils and the 
. principles of therapeutics impre.^sed upon the 
reader.— Fi-_7mti J/a/. Mo-thly, Mav, I8fc8. 



The second edition of his treatise is like his 
clinical instruction, admirably ai ranged, attractive 
in diction, and strikingly pra''tical throughout. 
The chapter on generally mptomatology is a model 
in its way ; no clearer dtscription of the various 

{)rimary*and consecutive lesions of the skin is to 
)e met with anywhere. Those on general diagno- 
sis and therapf'Utus are also worthy of careful 
fetudy. I-)r. Hyde has shown himself a compre- 
hensive render of the latest literature, and has in- 
corporated into his book all the best of that which 
the past yf-ars have brought forth. The prescrip- 
tions and formuliB are given in both common and 
metric sy.-..tem«. Text and illustrations are good, 
and colored plates (<i rare cases lend a Iditional 
attractions. Altogether i: is a work exactly fitted 
to the needs of a gnneial prai-titioner, and no one 
will make a mistake in jiirchasing it, — Medical 
rre^suf Wciitern Acio York, June, 1888. 



FOX, T., 31. D., ir.B. C. B., and BOX, T. C, B.A., 3I.B. C.S., 

Phyiiician to tlie I)cpariinent for Skiii Dmeases, Physician for Diseases of the Skin to the 

University College Hospital, London. Weatntinster Hospital, London. 

An Epitome of Skin Diseases. "With Formulse. For Students and Prac- 
titioners. Third edition, revised and enlarged. In one very handsome 12mo. volume 
of 238 i>ages. Cloili, $J .25. 

manual to lie upon the table for instant reference. 
Itsalphabetical arrangement is suited to this use, 
for all one has to know is the name of the disease, 
and here are its description and the appropriate 
treatment at hand and ready for instant applica- 
tion. The presf nt edition has been very carefully 
revised and a nnmljer of new diseases are de- 
scritied, while mo.st of the recent additions to 
dermal therapeutics find mention, and the formu- 
lary at the end of the book has been considerably 
augmented. — The Medical News, December, 1883. 



The third edition of this convenient handbook 
calls for notice owing to the revision and exjiansion 
which it has undergone. The arrangement of skin 
aifeasCM in alplia>>eti<ai order, which is the metliod 
of cljissirtr'aiion adojiied in this work, liecomes a 
positive a.hantay:»' to the student. The book is 
on*' which we chu stronely recommend, not only 
to >tU'l*'nts l>ut nl>^o t*. practiiioners who require a 
compendious snmmarv of the present state ot 
dermatology.— /i/ iri.<h Mejlirat Jovmiil, .July 2, 188:{. 

We cordially recommend Fox's F/x'/or/'e to those 
whosH time is limited and who wish a handy 



WILSON, BBASJIUS, B.B.S. 

The Student's Book of Cutaneous Medicine and Diseases of the Skin. 



In one hancU 



some .snia 



11 octavo volume of 535 pages. Cloth, $3.50. 



BH.LIKR'S TTANDBOOK OV RKIN DISEASE.^; 
l^r &tu<iini.s and Praciiiiouero. atccud Aiacn- 



can edition. In one 12mo. volume of 3jj pages, 
wuh plates. Cloili, $J,.-J.o. 



Lea Brothers & Co.'s Publications — Dis. of Women. 



27 



The American Systems of Gynecology and Obstetrics. 

Systems of Gynecology and Obstetrics, in Treatises by American 
Authors. Gynecology edited by Matthew D. Majstn, A. M., M. D., Professor of Obstetrics 
and Gynecology in the Medical Department of the University of Buffalo; and Obstet- 
rics edited by Barton Cooke Hirst, M. D., Associate Professor of Obstetrics in the 
University of Pennsylvania, Philadelphia. In four very handsome octavo volumes, con- 
taining 3612 pages, 1092 engravings a,nd 8 plates. Complete work just ready. Per vol- 
ume: Cloth, $5.00; leather, $6.00; half Russia, $7.00. For sale by subscription only. 
Address the Publishers. Full descriptive circular free on application. 

LIST OF CONTRIBUTORS. 



WILLIAM H. BAKER, M. D., 
ROBERT BATTEY, M. D., 
SAMUEL C. BUSEY, M. D., 
JAMES C. CAMERON, M. D., 
HENRY C. COE, A. M., M. D., 
EDWARD P. DAVIS, M. D., 
G. E. De SCHWEINITZ, M. D., 
E. C. DUDLEY, A. B., M. D., 
B, McE. EMMET, M. D., 
GEORGE J. ENGELMANN, M. D., 
HENRY J. GARRIGUES, A. M., M. D., 
WILLIAM GOODELL, A. M., M. D., 
EGBERT H. GRANDIN, A. M., M. D., 
SAMUEL W. GROSS, M. D., 
ROBERT P. HARRIS, M. D., 
GEORGE T. HARRISON, M. D., 
BARTON C. HIRST, M. D. 
STEPHEN Y. HOWELL, M. D., 
A. REEVES JACKSON, A. M., M. D., 
W. W. JAGGARD, M. D., 
EDWARD W. JENKS, M. D., LL. D., 
HOWARD A. KELLY, M. D., 

This is a very valuable contribution to the liter- 
ature of obstetrics. The editors, contributors and 
{mblishers are entitled to most hearty congratu- 
ations for the complete kind of work that has 
appeared. — The Obstetric Gazette, August, 1888. 

This, the companion work to the System of 
Gynecology by American Authors, equals it in the 
excellence of the subject-matter and the perfec- 
tion of the publishers' art. As a treatise for the 
use of the practitioner the work will be found to 
represent admirably the obstetric science of the 
day as exemplified in American practice.— 7%6 
Medical News, August 25, 1888. 

There can be but little doubt that this work will 
find the same favor with the profession that has 
been accorded to the "System of Medicine by 
American Authors," and the "System of Gynecol- 
ogy byAmerican Authors," One is at a loss to know 
what to say of this volume, for fear that just and 
merited praise may be mistaken for flattery. The 
subjects of some of the papers are discussed in 
various works on obstetrics, though not to the full 
extent that is found in this volume. The papers 
of Drs. Engelmann, Martin, Hirst, Jaggard and 
Reeve are incomparably beyond anything that can 
be found in obstetrical works. Certainly the Edi- 
tor may be congratulated for having made such a 
wise selection of his contributors.— Journal of the 
Ainerican Medical Association, Sept. 8, 1888. 



CHARLES CARROLL LEE, M. D., 
WILLIAM T. LUSK, M. D., LL. D., 
J. HENDRIE LLOYD, M. D , 
MATTHEW D. MANN, A. M., M. D., 
H. NEWELL MARTIN, F. R. S., M. D., 

D.Sc, M.A., 
RICHARD B. MAURY, M. D., 
C. D. PALMER, M. D., 
ROSWELL PARK, M. D., 
THEOPHILUS PARVIN, M. D., LL. D., 
R. A. F. PENROSE, M. D., LL. D., 
THADDEUS A. REAMY, A. M., M. D., 
J. C. REEVE, M. D., 
A. D. ROCKWELL, A. M., M. D., 
ALEXANDER J. C. SKENE, M. D., 
J. LEWIS SMITH, M. D., 
STEPHEN SMITH, M. D., 
R. STANSBURY SUTTON, A. M., M. D., 

LL. D., 
T. GAILLARD THOMAS, M. D., LL. D., 
ELY VAN DE WARKER, M. D., 
W. GILL WYLIE. M. D. 

In our notice of the "System of Practical Medi- 
cine by American Authors," we made the follow- 
ing statement: — "It is a work of which the pro- 
fession in this country can feel proud. Written 
exclusively by American physicians who are ac- 
quainted with all the varieties of climate in the 
United States, the character of the soil, the man- 
ners and customs of the people, etc., it is pecul- 
iarly adapted to the wants of American practition- 
ers of medicine, and it seems to us that every one 
of them would desire to have it." Every word 
thus expressed in regard to the "American Sys- 
tem of Practical Medicine" is applicable to the 
"System of Gynecology by .\merican .\uthors," 
which we desire now to bring to the attention of 
our readers. It, like the other, has been written 
exclusively by American physicians who are 
acquainted with all the characteristics of American 
people, who are well informed in regard to the 
peculiarities of American women, their manners, 
customs, modes of living, etc. As every practis- 
ing physician is called upon to treat dis^eases of 
females, and as they constitute a class to which 
the familly physician must give attention, and 
cannot pass over to a specialist, we do not know of 
a work in any department of medicine that we 
should so strongly recommend medical men gen- 
erally purchasing.— Oinci/iua^i 3Ied. News, July,18S7. 



TMOMAS, T. GAILLABI), M. 2>., 

Professor of Diseases of Wo7nen in the College of Physicians and Surgeons, N. T. 

A Practical Treatise on the Diseases of Women. Fifth edition, thoroughly 
revised and rewritten. In one large and handsome octavo volume of 810 jiages, with '266 
illustrations. Cloth, $5.00 ; leather, $6.00. 



That the previous editions of the treatise of Dr. 
Thomas were thought worthy of translation into 
German, French, Italian and Spanish, is enough 
to give it the stamp of genuine merit. At home it 
has made its way into the library of every obstet- 



rician and gyniecologist asasafe guide to practice. 
No ymall number of addition.^ have been made to 
the present edition to make it correspond to re- 
cent improvements in treatment — i\ic«;ir MediecU 
and Surgical Journal, Jan. 1881. 



XJDIS, ABTBJIIt IF., M. D., Lond., F.B. CI".. M.B. C.S., 

Assist. Obstetric Phpsician to Middlescv Hospital, late Physician to Bntish Lying-in Hospital. 
The Diseases of Women. Including their Pathology, Caiisiition, Symptoms, 
Diagnosis and Treatment. A >Ianual for Students and Tract itioners. In one handsome 
octavo volume of 57 1) pages, with 14b illustrations. Cloth, $o.00 ; leather, $4.00. 

are among the more common methods of treat- 
ment, aucl yet very little is saiii about ti\em in 
many of the text-books. The b«.Hik is oiu> to l^ 
warmly rooonunended especially to ^tudonts and 
general prnotitioners, who need a conoise but com- 
plete rfsumf of the whole subjecl. Speci.Hli.^tJS t«.K», 
will find many useful hints "in its pages'.— £tv:ron 
Alcd. and Surg'. Journ., March 2, iS^i 



It is A ^-iloasure to road a book so thoroughly 
good as this one. The special qualities which" are 
conspicuous are thoroughness in covering the 
whole ground, clearuoss' of description and con- 
ciseness ol statement. Another nu^rUcd feature of 
the book is the attention paid to the details of 
many minor surgical operations and procedures 
as, for instance, the use of tents, amplication of 
leeches, and use of hot water iujections. These 



28 Lea Brothers & Co.'s Publications — Dis. of Women, Midwfy. 
EMMET, THOMAS ABBIS, M. !>., XX. JD~ 

Surgeon to the WomarCs Hospital, New York, etc. 

The Principles and Practice of Gynsecology ; For the use of Students and 
Practitioners of Medici ne. New (third) edition, thoroughly revised. In one large and very 
handsome octavo volume of 880 pages, with 150 illustrations. Cloth, $5; leather, $6; 
very handsome half Russia, raised bands, §6.50. 

ance of the third edition of this well-known work. 
Embodying, as it does, the life-long experience of 



The time has passed when Emmet's Gynaecology 
was to be regarded as a book for a single country 
or for a single generation. It has always been his 
aim to popularize gynaecology, to bring it within 
easy reach of the general practitioner. The orig- 
inality of the ideas compels our admiration and 
respect. We may well take an honest pride in 
Dr. Emmet's work and feel that his book can 
hold its own against the criticism of two conti- 
nents. It represents all that is most earnest and 
most thoughtful in American gynsecology. — Amer- 
ican Journal of Obstetrics, May, 1885. 

We are in doubt whether to congratulate the 
author more than the profession upon the appear- 



one who has conspicuously distinguished himself 
as a bold and successful operator, and who has 
devoted so much attention to the specialty, we 
feel sure the profession will not fail to appreciate 
the privilege thus offered them of perusing the 
views and practice of the author. His earnestness 
of purpose and conscientiousness are manifest. 
He gives not only his individual experience but 
endeavors to represent the actual state of gynse- 
cological science and art. — British Medical Jour- 
nal, May 16, 1885. 



TAIT, LAWSOW, F.B. C. S., 

Fellow of the Eoyal Medico- Chirurgical Society^ London, Honorary Member of the Boston Gyne- 
cological Society, Surgeon to the Birmingham an^Midland Hospital for Women. 

Diseases of Women and Abdominal Surgery. In one very handsome 

octavo volume of 600 pages, fully illustrated. In press. 

DAVENPOnT, F. XT., M. D., 

Assistant in Gyncecology in the Medical Department of Harvard University, Boston. 

Diseases of Women, a Manual of Non-Surgical Gynaecology. De- 
signed especially for the Use of Students and General Practitioners. In one handsome 
12mo. volume of 317 pages, with 105 illustrations. Cloth, $1.50. Just ready. 

FROM THE PREFACE. 

This book has two main objects: in the first place to give the student clearly but 
with considerable detail the elementary principles of the methods of examination and the 
simple forms of treatment of the most common diseases of the pelvic organs ; and in the 
second place to help the busy general practitioner to understand and treat the gynaecolog- 
ical cases which he meets with in the course of his everyday practice. The treatment 
has been mainly confined to such measures as have been practically found of the greatest 
benefit in the author's hands. 

JDUWCAJ^, jr. MATTMEWS, M.I)., LL. I)., F. B. 8. E., etc. 

Clinical Lectures on the Diseases of Women ; Delivered in Saint Bar- 
tholomew's Hospital. In one handsome octavo volume of 175 pages. Cloth, $1.50. 

rule, adequately handled in the text-books ; others 
of them, while bearing upon topics that are usually 
treated of at length in such works, yet bear such a 
stamp of individuality that they deserve to be 



They are in every way worthy of their author ; 
Indeed, we look upon them as among the most 
valuable of his contributions. They are all upon 
matters of great interest to the general practitioner. 
Some of them deal with subjects that are not, as a 



widely read.— iV. Y. Medical Journal, March, 1880. 



MAY, CSABLES H., M. J>., 

Late House Surgeon to Mount Sinai Hospital, New York. 

A Manual of the Diseases of Women. Being a concise and systematic expo- 
sition of the theory and practice of gynsecology. In one 12mo. volume of 342 pages; 
Cloth, $1.75. 

HODGE, HUGHE., M. D., 

Emeritus Professor of Obstetrics, etc., in the University of Pennsylvania. 

On Diseases Peculiar to Women; Including Displacements of the Uterus. 
Second edition, revised and enlarged. In one beautifully printed octavo volume of 619 
pages, with original illustrations. Cloth, $4.50. 

By the Same Author. 

The Principles and Practice of Obstetrics. Illustrated with large litho- 
graphic plates containing 159 figures from original photographs, and with numerous wood- 
cuts. In one large quarto volume of 542 double-columned pages. Strongly bound in 
cloth, $14.00. Specimens of the plates and letter-press will be forwarded to any address, 
free by mail, on receipt of six cents in postage stamps. 

MAMSBOTHAM, FBANCIS H., M. D. 

The Principles and Practice of Obstetric Medicine and Surgery: 

In reference to the Process of Parturition. A new and enlarged edition, thoroughly revised 
by the Author. With additions by W. V. Keating, M. D., Professor of Obstetrics, etc., 
in the Jefferson Medical College of Philadelphia. In one large and handsome imperial 
octavo volume of 640 pages, with 64 full-page plates and 43 woodcuts in the text, contain- 
ing in all nearly 200 beautiful figures. Strongly bound in leather, with raised bands, $7. 

WEST, CHABLES, M. D. 

Lectures on the Diseases of Women. Third American from the third Lon- 
don edition. In one octavo volume of 543 pages. Cloth, $3.75 ; leather, $4.75. 



Lea Brothers & Co.'s Publications — Midwifery, 



29 



PABVIN, THEOI'HILVS, M. D., LL. D., 

Prof, of Obstetrics and the Diseases of Women and. Children in Jefferson Med, Coll., Phila. 

The Science and Art of Obstetrics. In one handsome 8vo. volume of 697 
pages, with 214 engravings and a colored plate. Cloth, ^4.25 ; leather, $5.25. 

It is a ripe harvest that Dr. Parvin offers to his 
readers. There is no book that can be more safely- 



recommended to the student or that can be turned 
to in moments of doubt with greater assurance of 
aid, as it is a liberal digest of safe counsel that has 
been patiently gathered. — The American Journal 
of the Medical Sciences, July, 1887. 

There is not in the language a treatise on the 
subject which so completely and intelligently 
ttleans the whole field of obstetric literature, giv- 
ing the reader the winnowed wheat in concise and 



well-jointed phrase, in language of exceptional 
purity and strength. The arrangement of the 
matter of this work is unique and exceedingly 
favorable for an agreeable unfolding of the science 
and art of obstetrics. This new book is the easy 
superior of any single work among its predeces- 
sors for the student or practitioner seeking the 
best thought of the day in this department of 
medicine. — The American Practitioner and News, 
April 2, 1887. 



BABNBS, MOBBBT, M. !>., and FAJVCOUBT, M. JD., 

Phys. to the General Lying-in JSosp., Lond. Obstetric Phys. to St. Thomas' Eosp., Lond. 

A System of Obstetric Medicine and Surgery, Theoretical and Clin- 
ical. For the Student and the Practitioner. The Section on Embryology contributed by 
Prof. Milnes Marshall. In one handsome octavo volume of 872 pages, with 231 illus- 
trations. Cloth, $5 ; leather, $6. 



The immediate purpose of the work is to furnish 
a handbook of obstetric medicine and surgery 
for the use of the student and practitioner. It is 
not an exaggeration to say of the book that it is 
the best treatise in the English language yet 
published, and this will not be a surprise to those 
who are acquainted with the work of the elder 
Barnes. Every practitioner who desires to have 



the best obstetrical opinions of the time in a 
readily accessible and condensed form, ought to 
own a copy of the book. — Journal of the American 
Medical Association, June 12, 1886. 

The Authors have made a text-book which is in 
every way quite worthy to take a place beside the 
best treatises of the period. — New York Medical 
Journal^ July 2, 1887. 



rZATFAIB, W. S., M. ZP., F. B. C. !>., 

Professor of Obstetric Medicine in King's College, London, etc. 

A Treatise on the Science and Practice of Midwifery. New (fifth) 
American, from the seventh English edition. Edited, with additions, by Egbert P. Har- 
ris, M. D. In one handsome octavo volume of about 700 pages, with 3 plates and about 
200 engravings. In press. 

A notice of the previous edition is appended. 



Students and practitioners alike have already 
found out the advantage of possessing a work em- 
bodying all the recent advances in the science 
and practice of midwifery. It has deservedly be- 
come a standard treatise upon the subject. The 
Author has endeavored to dwell especially on the 
practical part of the subject, so as to make the 
work a useful guide in this most anxious and re- 



sponsible branch of the profession. At the same 
time, the purely theoretical portion has not been 
neglected. Dr. Playfair's treatise may fairly be 
said to represent the modern school of teaching. 
It is a well-arranged and carefully digested 
epitome of the science and practice of midwifery 
which has greatly contributed to the advancement 
of the study. — British Medical Journal, Jan. 3, 1885. 



KIJ^G, A. F. A., M. D., 

Professor of Obstetrics and I>i,seases of Women in the Medical Department of the Columbian Univer- 
sity, Washington, D. C, and in the University of Vermont, etc. 

A Manual of Obstetrics. New (fourth) edition. In one very handsome 12mo. 
volume of about 400 pages, with 140 illustrations. In press. 
A notice of tlie previous edition is appended. 



This little manual, certainly the bestof itskind^ 
fully deserves the popularity which has made a 
third edition necessary. Clear, practical, concise. 
Its teachings are so fully abreast with recent ad- 



vances in obstetric science that but few points 
can be criticised. — American Journal of Obstetrics, 
March, 1887. 



BABKEB, FOBDTCF, A. M., M. D., LL. D. Edin., 

Clinical Professor of Midwifery and the Diseases of Women in the Belleinie Hospital Medical College, 
New York, Honorary Fellow of the Obstetrical Societies of London and Ediuburgk, etc., etc. 

Obstetrical and Clinical Essays. In one handsome 12mo. volimie of about 
300 pages. Preparing. 

:PABBY, JOHN S., M. J>., 

Obstetrician to the Philadelphia Hospital, Vice-Presidei\t of the Obstef^ Society of Philadelphia, 
Extra - Uterine Pregnancy: Its Cliniavl liistory, Diagnosis', Prognosis and 
Treatment. In one handsome octavo volume of 272 pages. Cloth, '^'2.50. 



WIKCKEL, F. 

A Complete Treatise on the Pathology and Treatment of Childbed, 
For Students and Practitioners. Translated, with the ctmsent of the Author, frvnu the 
second German edition, by J. R. Chadwiok, M. D. Octavo 484 pages. Cloth, $4.00. 



ASHWELL'S PRACTICAL TREATISE ON THE 
DISEASES PECULIAR TO WOMEN. Third 
American from the tliird and revised LouiUni 
edition. In one 8vo. vol., pp. 520. Cloth. ^\M. 

TANNER ON PRFX^ NANCY. Octavo, 490 pages, 
colored plates, IG cuts. Cloth, $4.J5. 



CHURCHILL ON THE PUERPERAL FEVER 
AN1> OTHER DISEASES PECULIAR TO WO- 
!\1EN. In one 8vo. vol. of 4(U p.'ices. Cloth, f-J. 50. 

MEIG8 ON THE NATURE. SU^NV AND TREAT- 
MEN T OF CHILUHEP FEVER- lu cue Sva 
volume of 340 pages. Cloth, f2.i.Kii. 



Allen's Anatomy .... 6 

American Journal of the Medical Sciences . 3 

American Systems'of Gynecology and Obstetrics 27 

American System of Practical Medicine . . 15 

An American System of Dentistry . . 24 

Ashhurst's Surgery ..... 20 

Ash well on Diseases of "Women . . .29 

Attfield's Chemistry 

Ball on the Kectum and Anus . . . 4, 20 

Barker's Obstetrical and Clinical Essays, . 29 

Barlow's Practice of Medicine . . .17 

Barnes' System of Obstetric Medicine . . 29 

Bartholow on Electricity .... 17 

Bartholow's Is ew Remedies and their Uses . 11 

Basham on Renal Diseases 

Bell's Comparative Physiology and Anatomy . 4, 7 

Bellamy's Surgical Anatomy 

Billings' Universal Medical Dictionary 

Blandford on Insanity ... - 19 

Bloxam's Chenaistry 

Bristowe's Practice of Medicme ... 14 

Broadbent on the Pulse . . . . 4, 18 

Browne on the Ophthalmoscope . . . 23 

Browne on the Throat, Nose and Ear . . 18 

Bruce's Materia Medica and Therapeutics . 11 

Brunton's Materia Medica and Therapeutics . 11 

Bryant's Practice of Surgery .... 21 

Bumstead and Taylor on Venereal. See Taylor. 25 

Burnett on the Ear . . . . .23 

Butlin on the Tongue . . . . . 4, 21 

Carpenter on the Use and Abuse of Alcohol 

Carpenter's Human Physiology 

Carter & Frost's Ophthalmic Surgery . .4,23 

Chambers on Diet and Regimen ... 17 

Chapman's Human Physiology 

Charles' Physiological and Pathological Chem. 

Churchill on Puerperal Fever 

Clarke and Lockwood's Dissectors' Manual 

Classen's Quantitative Analysis 

Cleland's Dissector .... 

Clouston on Insanity .... 

Clowes' Practical Chemistry 

Coats' Pathology .... 

Cohen on the Throat . . ^ . 

Coleman's Dental Surgery . 

Condie on Diseases of Children 

Cornil on Syphilis .... 

Dalton on the Circulation 

Dalton's HumanPhysiology 

Davenport on Diseases of Women . 

Davis' Clinical Lectures 

Draper's Medical Physics 

Drmtt's Modern Surgery 

Duncan on Diseases of "Women 

Dungllson's Medical Dictionary 

Edes' Materia Medica and Therapeutics 

Edis on Diseases of "Women . 

Ellis' Demonstrations of Anatomy 

Emmet's Gynaecology 

Erichsen's System of Surgery 

Farquharson's Therapeutics and Mat. Med. 

Fenwick's Medical Diagnosis 

Finlayson's Clinical Diagnosis 

Flint on Auscultation and Percussion 

FUnt on Phthisis .... 

Flint on Respiratory Organs 

Flint on the Heart . . ^ . 

Flint's Essays . . . ** . 

Flint's Practice of Medicine 

Folsom's Laws of U. S. on Custody of Insane 

Foster's Physiology .... 

Fothergill's Handbook of Treatment 

Fownes' Elementary Chemistry . , 

Fox on Diseases of the Skin . 

Frankland and Japp's Inorganic Chemistry 

Fuller on the Lungs and Air Passages . 

Gibney's Orthopaedic Surgery 

Gk)uld's Surgical Diagnosis . 

Gray's Anatomy ..... 

Greene's Medical Chemistry . 

Green's Pathology and Morbid Anatomy 

Griffith's Universal Formulary 

Gross on Foreign Bodies in Air-" 

Gross on Impotence and Sterility . 

Gross on Urinary Organs 



Gross' System of Surgery 
Habershon on the Abdomen 
Hamilton on Fractures aiM Dislocations 
Hamilton on Nervous Diseases 
Hartshorne's Anatomy and Physiology . 
Hartshorne's Conspectus of the Med. Sciences 
Hartshorne's Essentials of Medicine 
Hermann's Experimental Pharmacology 
Hill on Syphilis ..... 
Hillier's Handbook of Skin Diseases 
Hoblyn's Medical Dictionary 
Hodge on Women .... 

Hodge's Obstetrics .... 
Hoffmann and Power's Chemical Analysis 
Holden's Landmarks .... 
Holland's Medical Notes and Reflections 
Holmes' Principles and Practice of Surgery 
Holmes' System of Surgery 
Horner's Anatomy and Histology 
Hudson on Fever 
Hutchinson on Syphilis 
Hyde on the Diseases of the Slcln . 



4 

4,25 



Jones (C. Handfield) on Nervous Disorders . 19 
Juler's Ophthalmic Science and Practice . 23 

King's Manual of Obstetrics . . . .29 

Klein's Histology . . . . . . 4, 13 

Landis on Labor . . . . ^'' . 30 

La Roche on Pneumonia, Malaria, etc. . . 18 

La Roche on Yellow Fever .... 14 

Laurence and Moon's Ophthalmic Surgery . 23 
Lawson on the Eve, Orbit and Eyelid . . 23 

Lea's Studies in Church History . . .31 

Lea's Superstition and Force . . .31 

Lee on Syphilis ... 25 

Lehmann's Chemical Physiology ... 8 
Leishman's Midwifery .... 30 

Lucas on Diseases of the Urethra . . .4,24 

Ludlow's Manual of Examinations . . 3 

Lyons on Fever ...... 14 

Maisch's Organic Materia Medica . . .11 

Marsh on the Joints . . . 4 21 

ISIay on Diseases of "Women .... 28 

Medical News . ... 1 

Medical News Visiting List . . . .3 

Medical News Physicians' Ledger ... 3 
Meigs on Childbed Fever .... 29 

Miller's Practice of Surgery . . ... 21 

Miller's Principles of Surgery . . .21 

Mitchell's Nervous Diseases of "Women . . 19 

Morris on Diseases of the Kidney . . .4,24 

Neill and Smith's Compendium of Med. Sci. . 3 
Nettleship on Diseases of the Eye . . .23 

Norris and Oliver on the Eye ... 23 

Owen on Diseases of Children . . . 4, 30 

Parrish's Practical Pharmacy ... 11 

Parry on Extra-Uterine Pregnancy . . 29 

Parvin's Midwifery ... . .29 

Pavy on Digestion and its Disorders . . 17 

Payne's General Pathology .... 13 

Pepper's System of Medicine ... 15 

Pepper's Forensic Medicine . . . . 4, 31 

Pepper's Surgical Pathology . . . 4. 13 

Pick on Fractures and Dislocations . . 4. 22 

Pirrie's System of Surgery . ... 21 

Playfair on Nerve Prostration and Hysteria . 19 
Play fair's Midwifery ..... 29 

Politzer on the Ear and its Diseases . . 23 

Power's Human Physiology . . . . 4. 8 

Purdy on Bright's Disease and Allied A fiections 24 
Ralfe's Clinical Chemistry . . . 4, 10 

Ramsbotham on Parturition . . . 28 

Remsen's Theoretical Chemistry ... 10 
Reynolds' System of Medicine . . . 16 

Richardson's Preventive Medicine . - . 17 

Roberts on Urinary Diseases ... 24 

Roberts' Compeud of Anatomy ... 7 
Roberts' Principles and Practice of Surgery . 20 
Robertson's Physiological Physics . . 4, 7 

Ross on Nervous Diseases .... 19 

Savage on Insanity, including Hysteria . . 4, 19 

Schaier's Essentials of Histology, . . 13 

Schreiber on Massage . ... 17 

Seller on the Throat, Nose and Naso-Pharynx 18 
Senn's Surgical Bacteriology ... 13 

Series of Clinical Manuals .... 4 

Simon's Manual of Chemistry ... 9 
Slade on Diphtheria . .... 18 

Smith (Edward) on Consumption . . .18 

Smith (J. Lewis) on Children ... 30 

Smith's Operative Surgery .... 22 

Stllle on Cholera 16 

Stillg & Maisch's National Dispensatory . 12 

Stillg's Therapeutics and Materia Medica . 11 

Stimson on Fractures and Dislocations . 22 

Stimson's Operative Surgery ... 22 

Students' Series of Manuals .... 4 
Sturges' Clinical Medicine . . . .17 

Tait's Diseases of "Women and Abdom. Surgery 28 
Tanner on Signs and Diseases of Pregnancy . 29 
Tanner's Manual of Clinical Medicine . . 16 

Taylor's Atlas of Venereal and Skin Diseases 26 
Taylor on Venereal Diseases . . . 25 

Taylor on Poisons ..... 31 
Taylor's Medical Jurisprudence ... 31 
Taylor's Prin. and Prac. of Med. Jurisprudence 31 
Thomas on Diseases of Women . . .27 

Thompson on Stricture . ... 24 

Thompson on Urinary Organs . . .24 

Tidy's Legal Medicine . . ... 31 

Todd on Acute Diseases . . . .17 

Treves' Manual of Surgery .... 21 
Treves' Surgical Applied Anatomy . . 4, 6 

Treves on Intestinal Obstruction . . .4,21 

Tukeon the Influence of Mind on the Body . 19 
Vaughan <fe Novy's Ptomaines and Leucomalnea 16 
Visiting List, The Medical News ... 3 
"Walshe on the Heart ..... 18 
Watson's Practice of Physic . . . .14 

Wells on the Eye 23 

Weston Diseases of Women . . .28 

West on Nervous Disorders in Childhood . 30 

Williams on Consumption .... 18 
Wilson's Handbook of Cutaneous Medicine . 26 
Wilson's Human Anatomy .... 6 
Winckel on Pathol, and Treatment of Childbed 29 
Wohler's Organic Chemistry ... 8 

Woodhead's Practical Pathology . . .13 

Year-Books of Treatment for 1886, 1887 and 1889. 17 



LEA BROTHERS & CO., Philadelphia. 



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